Mode of Delivery, Prolonged Breastfeeding and Diet as Predictors of Severe Early Childhood Caries: a Multicenter Study in Children Under 3 Years

Mode of Delivery, Prolonged Breastfeeding and Diet as Predictors of Severe Early Childhood Caries: a Multicenter Study in Children Under 3 Years | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Mode of Delivery, Prolonged Breastfeeding and Diet as Predictors of Severe Early Childhood Caries: a Multicenter Study in Children Under 3 Years Kelly Fernanda Molena, Letícia Yin Chun Lin, Isabela do Carmo Custodio, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7594850/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose This study aimed to evaluate whether the mode of delivery, breastfeeding practices, and dietary habits were associated with severe early childhood caries (S-ECC) in children under 3 years of age from Brazil and the United States. Methods This retrospective study adhered to the STROBE guidelines. Data were retrieved from electronic medical records of 700 children aged 0–3 years who underwent complete oral examinations between August 2021 and November 2023. Collected variables included mode of delivery, diet, type and duration of breastfeeding, nationality, oral hygiene habits, age, and sex. Statistical analyses were conducted using chi-square tests, the Mann–Whitney U test, and multiple linear regression, with a significance level set at 5%. Results The overall prevalence of S-ECC was 59.4% (416/700), with 41.1% of cases from the United States and 18.2% from Brazil. Of the total sample, 51.9% were male and 48.1% female, with a mean age of 1.75 years. In bivariate analyses, vaginal delivery (p < 0.001) and cariogenic diet (p < 0.001) were significantly associated with S-ECC. In the multivariable regression model, older age (B = 0.107, p < 0.001), longer breastfeeding duration (B = 0.005, p < 0.001), and U.S. nationality (B = − 2.918, p < 0.001) remained independent predictors of higher dmft scores. Other variables were not significant. Conclusion S-ECC was highly prevalent in this sample, affecting nearly six in ten children under 3 years of age. While vaginal delivery and cariogenic diet were associated with S-ECC in unadjusted analyses, only age, breastfeeding duration, and nationality emerged as independent predictors after adjustment. These findings underscore the multifactorial nature of S-ECC and the need for early, culturally tailored preventive strategies. Dental caries Breastfeeding Child nutrition Mode of delivery Multicenter study Figures Figure 1 Figure 2 INTRODUCTION According to the American Academy of Pediatric Dentistry (AAPD, 2025), Early Childhood Caries (ECC) is defined as the presence of decayed, missing (due to caries), or filled tooth surfaces in any primary tooth of a child under 72 months of age. Severe Early Childhood Caries (S-ECC) refers to smooth-surface caries in children under 3 years, or—between ages 3 and 5—cases meeting specific thresholds (≥ 4 affected surfaces at age 3, ≥ 5 at age 4, and ≥ 6 at age 5). While most studies have examined ECC in children up to 6 years of age (Boustedt et al., 2021 ; Shrestha et al., 2024 ), the present investigation specifically addresses children under 3 years old. This early stage, encompassing the first 1,000 days of life, is recognized as a critical window for implementing actions and interventions that can influence long-term oral and systemic health. Focusing on this period may provide a deeper understanding of the risk factors for early caries development in this highly vulnerable population (Abanto et al., 2022 ). The development of ECC is influenced by multiple risk factors, including dietary habits, family socioeconomic status, parental education, and oral hygiene practices. Additional determinants include demographic characteristics, parental attitudes toward dental care, a child’s temperament, and health-related behaviors such as mouth breathing (Al-Sane et al., 2021 ; Boustedt et al., 2021 ; Lin et al., 2022 ; Araújo et al., 2022 ; Sahu et al., 2023 ; Mathias et al., 2023 ; Suresh et al., 2023 ; Foxman et al., 2023 ; Saheb et al., 2023 ). A particular area of interest is the mode of delivery, as recent years have seen a substantial rise in cesarean section births compared with vaginal deliveries (Angolile et al., 2023 ). The mode of delivery may have lasting implications for a child’s oral health, as studies suggest that the oral microbiota acquired during birth can differ according to delivery method. Vaginal delivery is associated with a higher prevalence of beneficial bacteria, possibly reducing the early colonization of Streptococcus mutans, a key pathogen in ECC (Li et al., 2005 ). Nevertheless, evidence on the relationship between delivery mode and ECC remains inconsistent. Some studies have found weak or inconclusive associations between cesarean delivery and increased ECC prevalence (Raj et al., 2018 ; Zhou et al., 2021; Boustedt et al., 2021 ), whereas others reported no differences (Ladeira et al., 2021 ) or even suggested an increased risk associated with cesarean section (Ge et al., 2023 ). These inconsistencies highlight the need for further investigation, particularly in young children from diverse backgrounds. The World Health Organization (WHO, 2025) recommends exclusive breastfeeding for the first six months of life, with continued breastfeeding alongside complementary feeding until two years of age or longer. However, prolonged breastfeeding, particularly beyond 24 months and when combined with frequent cariogenic feeding and inadequate oral hygiene, has been linked to a heightened risk of S-ECC (Peres et al., 2017 ; Mathias et al., 2023 ). The literature remains conflicting: some studies associate extended breastfeeding with higher rates of ECC (Du et al., 2018 ; Mathias et al., 2023 ; Al-Ansari et al., 2024), while others report no significant correlation (Du et al., 2007 ; Branger et al., 2019 ; Devenish et al., 2020 ; Bulut et al., 2023). Therefore, this study aims to investigate the interrelationships between mode of delivery, dietary practices, and breastfeeding duration, and their association with S-ECC in children aged 0 to 3 years from Brazil and the United States. METHODS Ethical aspects This study was approved by the Research Ethics Committee of the XXX as a multicenter study and by the Institutional Review Board of the University of XXX. It was conducted in accordance with the Declaration of Helsinki. Informed consent for participation and publication was obtained from all participants’ legal guardians. This retrospective multicenter study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (Cuschieri, 2019 ). Study design This was a retrospective multicenter cross-sectional study aimed at investigating whether mode of delivery, prolonged breastfeeding, and dietary habits act as risk factors for S-ECC. Data were obtained from electronic medical records, allowing standardized review of clinical information for children aged 0–3 years. Setting The study was conducted in Brazil and the United States across participating institutions (XXX). Data were collected between August 2021 and November 2023. Eligible participants were children diagnosed or not with S-ECC who underwent comprehensive dental examinations as part of their routine clinical assessments. Participants Inclusion criteria: Children aged 0–3 years registered in the electronic medical records of XXX and XXX. Children with or without a clinical diagnosis of S-ECC. Access to fluoridated water. Complete medical records containing information on mode of delivery, number of cavitated teeth, dietary habits, and breastfeeding history. Presence of at least one fully erupted primary tooth. Exclusion criteria: Children with disabilities affecting oral hygiene or dietary practices. Children with enamel defects or congenital anomalies of the dentition. Incomplete medical records lacking essential information (e.g., breastfeeding or diet). Insufficient contact with guardians to clarify data ambiguities. Variables Dental caries in the primary dentition was measured using the decayed, missing, and filled teeth (dmft) index, according to WHO (2013) criteria. Decayed teeth were recorded only when lesions extended into dentin, excluding enamel-only lesions. Missing teeth were included only if extraction was attributed to caries, based on dental development and caries pattern. Filled teeth were recorded if restorations were placed due to caries, considering type, size, and condition of the dentition. The primary outcome variable was severe early childhood caries (S-ECC), defined according to WHO thresholds (WHO, 1997). The main independent variables of interest were mode of delivery (vaginal vs. cesarean), type of breastfeeding (exclusive or mixed), breastfeeding duration (in days), and dietary habits (consumption of industrialized sugar-containing foods). Potential confounders included child’s age, sex, nationality (Brazil or USA), oral hygiene practices (frequency of toothbrushing and use of toothpaste with ≥ 1000 ppm fluoride), and bottle-feeding practices. Data sources, measurement, and bias control Dental caries examinations were conducted by calibrated dental students across all participating institutions to ensure inter-center reliability. Data were consolidated by a single investigator, based on information provided by institutional informatics teams. All variables were derived from structured assessments and included both quantitative (e.g., number of cavitated teeth) and qualitative (e.g., breastfeeding type, dietary practices) data. To minimize bias, assessment protocols were standardized across centers. Data underwent secondary review for accuracy, and guardian validation was sought when necessary. Missing data were managed through follow-up contact with families or through statistical procedures, though the proportion of missing data was low (< 5%). Study size Sample size was estimated prior to data collection to ensure sufficient power to detect expected effects, based on reported ECC prevalence rates of 18.6% among U.S. children (Kotha et al., 2022 ) and 17% among Brazilian children (Moimaz et al., 2016 ). Using OpenEpi version 3.01, a minimum sample of 233 children was calculated (5% standard error). However, all available eligible records were included, yielding a final convenience sample of 700 children, thus exceeding the minimum requirement and ensuring adequate statistical power. Statistical analyses Analyses were performed using IBM SPSS Statistics version 21.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics (means, standard deviations, medians, interquartile ranges, and frequencies) were computed for all variables. Bivariate associations were tested using the chi-square test for categorical variables and the Mann–Whitney U test for continuous variables, after confirming non-normal distributions. A multiple linear regression model was built to identify independent predictors of dmft. Variables of theoretical and clinical importance were initially included: sex, age, nationality, mode of delivery (vaginal/cesarean), breastfeeding duration (days), exclusive breastfeeding, bottle-feeding, cariogenic diet, number of sugar-containing foods, frequency of toothbrushing, and use of fluoridated toothpaste (≥ 1000 ppmF). Multicollinearity was assessed through variance inflation factors (VIF) and tolerance values, with VIF < 2 considered acceptable. Model assumptions were verified through residual analysis, and overall model fit was evaluated using R², adjusted R², and the F-test for significance. RESULTS A total of 857 records were screened for eligibility. After screening records from both participating centers and applying the eligibility criteria, 700 children were included in the final analytic sample (Brazil: n = 268; USA: n = 432). Records were excluded primarily for ineligibility (age outside the target range), missing key variables (e.g., dmft, mode of delivery, breastfeeding, or diet information), incomplete dental charts, or duplicate entries. The full screening and exclusion pathway is detailed in Fig. 1 . Table 1 presents the distribution of S-ECC according to sociodemographic, perinatal, feeding, dietary, and oral-hygiene variables, and the chi-square tests indicated several significant associations. Overall, 48.1% of the sample were female and 51.9% male, with no significant difference in S-ECC prevalence between sexes (p = 0.071). Regarding ethnicity, most children were White (55.4%), followed by Black (14.3%), mixed-race (9.9%), and smaller proportions identified as Yellow (4.9%) or not informed (15.6%); no significant differences were observed across groups (p = 0.399). Table 1 Descriptive data of the sample and comparison of proportions of sociodemographic data, mode of delivery, feeding, diet, and oral hygiene habits. Variables S-ECC No Yes Total % p* Sociodemographic data Sex Female 125 212 337 48.14 0.071 Male 159 204 363 51.85 Ethnicity Black 46 54 100 14.28 0.399 Brown 33 36 69 9.85 White 150 238 388 55.42 Yellow 15 19 34 4.85 N/I 40 69 109 15.57 Nationality BRA 140 128 268 32.28 < .001 USA 144 288 432 61.71 Mode of delivery Cesarean 132 128 260 31.14 < .001 Vaginal 152 288 440 62.85 Feeding and diet Exclusive breastfeeding No 82 76 158 22.57 < .001 Yes 193 340 533 76.14 N/I 9 0 9 1.28 Night breastfeeding No 41 55 96 13.71 0.392 Yes 194 214 408 58.28 N/I 49 147 196 28 Feeding bottle No 93 246 339 48.42 < .001 Yes 190 169 359 51.28 N/I 1 1 2 0.28 Mixed breastfeeding (bottle and breast) No 91 88 179 25.57 0.569 Yes 48 40 88 12.57 N/I 145 288 433 61.85 Cariogenic diet No 121 84 205 29.28 < .001 Yes 160 329 489 69.85 N/I 3 3 6 0.85 Hygiene habits Hygiene after breastfeeding or bottle No 60 56 116 16.57 0.346 Yes 40 29 69 9.85 N/I 184 331 515 73.57 Fluoride toothpaste (≥ 1000ppmF) No 90 37 127 18.14 < .001 Yes 183 371 554 79.14 N/I 11 8 19 2.71 * χ² Tests, S-ECC: Severe early childhood caries, N/I: Not informed Nationality showed a significant association with S-ECC (p < 0.001). Most participants were born in the United States (61.7%), where the proportion of children with S-ECC (66.7%) was higher compared with Brazil (32.3% of the sample; 47.8% with S-ECC) ( Fig. 2 a ). Mode of delivery also differed significantly (p < 0.001): vaginal delivery accounted for 62.9% of the sample and was associated with a higher prevalence of S-ECC (65.5%) compared with cesarean section (31.1% of the sample; 49.2% with S-ECC) ( Fig. 2 b ) . Feeding practices further revealed significant differences. Exclusive breastfeeding was reported by 76.1% of the children and was more common among those with S-ECC (63.8%) compared with those without (48.1%; p < 0.001) ( Fig. 2 c ) . In contrast, bottle-feeding was reported by 51.3% of the sample and was significantly less frequent among children with S-ECC (47.1%) than among those without (72.6%; p < 0.001) ( Fig. 2 d ) . Dietary habits showed a strong relationship with caries. A cariogenic diet was reported by 69.9% of the children, among whom S-ECC was substantially more frequent (67.3%) compared with those without such a diet (41.0%; p < 0.001) ( Fig. 2 e ) . With regard to oral-hygiene practices, the use of fluoride toothpaste containing ≥ 1000 ppmF was reported by 79.1% of the children and was significantly more common among those with S-ECC (67.0%) than among their counterparts without caries (29.1%; p < 0.001) ( Fig. 2 f ) . Conversely, hygiene after breastfeeding or bottle-feeding was reported in only 9.9% of the sample and was not associated with differences in S-ECC prevalence (p = 0.346). In the total sample of 700 children, 416 presented S-ECC, corresponding to a prevalence of 59.4%. According to the Mann–Whitney U test ( Table 2 ) , children with S-ECC (n = 416) were significantly older than those without the condition (n = 284) (mean 23.72 ± 7.13 vs. 17.81 ± 9.07 months; median 24 [IQR 24–24] vs. 12 [IQR 12–24]; p < 0.001). Breastfeeding duration was also longer in the S-ECC group (n = 415; mean 452.76 ± 351.98 days; median 365 [IQR 180–730]) compared with children without S-ECC (n = 269; mean 210.84 ± 235.20 days; median 180 [IQR 0–365]; p < 0.001). In contrast, bottle-feeding duration was longer among children without S-ECC (n = 114; mean 441.25 ± 405.98 days; median 365 [IQR 0–731]) than among those with S-ECC (n = 127; mean 339.48 ± 415.31 days; median 0 [IQR 0–730]; p = 0.015). Children with S-ECC also reported more frequent intake of sugar-containing foods (n = 412; mean 2.24 ± 2.05 episodes/day; median 2 [IQR 1–3]) compared with those without S-ECC (n = 281; mean 1.44 ± 1.78 episodes/day; median 1 [IQR 0–3]; p < 0.001). Finally, toothbrushing frequency was slightly higher in the S-ECC group (n = 389; mean 1.82 ± 0.81 episodes/day; median 2 [IQR 1–2]) than in children without S-ECC (n = 277; mean 1.53 ± 0.93 episodes/day; median 2 [IQR 1–2]; p < 0.001). Table 2 Descriptive analysis including age, breastfeeding duration (days), bottle-feeding duration (days), daily intake of sugar-containing foods, and number of daily toothbrushing episodes, and their association with Severe Early Childhood Caries (S-ECC, assessed using the decayed, missing, and filled teeth index – dmft). Percentiles S-ECC N Mean (SD) Median 25th 75th p* Age (months) No 284 17.81 (9.070) 12.00 12.00 24.00 < .001 Yes 416 23.72 (7.125) 24.00 24.00 24.00 Breastfeeding (days) No 269 210.84 (235.198) 180 0.00 365.00 < .001 Yes 415 452.76 (351.979) 365 180.00 730.00 Bottle (days) No 114 441.25 (405.983) 365.00 0.00 731.00 0.015 Yes 127 339.48 (415.307) 0 0.00 730.00 Sugary food (daily) No 281 1.44 (1.778) 1 0.00 3.00 < .001 Yes 412 2.24 (2.049) 2.00 1.00 3.00 Number of brush (daily) No 277 1.53 (0.934) 2 1.00 2.00 < .001 Yes 389 1.82 (0.810) 2 1.00 2.00 *Mann-Whitney U test, Note. Hₐ µ No ≠ µ Yes To further explore the independent contribution of different factors associated with severe early childhood caries (S-ECC), measured by the dmft index, a multiple linear regression analysis was conducted ( Table 3 ) . This approach was employed because the chi-square and Mann–Whitney tests, although informative, assess each variable separately and do not account for potential interrelationships among sociodemographic, perinatal, feeding, dietary, and oral-hygiene variables. By including them simultaneously, the regression model allows for the identification of predictors that remain significantly associated with S-ECC after adjustment for confounding factors. For transparency, the complete regression outputs are provided in the Supplementary Material. The final model was statistically significant (F(11, 623) = 13.529; p < 0.001) and explained 19.3% of the variance in dmft scores (R² = 0.193; adjusted R² = 0.179). Among the independent variables, child’s age (B = 0.107; 95% CI: 0.05–0.17; p < 0.001), nationality (USA vs. Brazil; B = − 2.918; 95% CI: − 3.97 to − 1.87; p < 0.001), and breastfeeding duration in days (B = 0.005; 95% CI: 0.00–0.01; p < 0.001) were significantly associated with higher dmft values. Other variables that appeared significant in bivariate analyses—such as mode of delivery, exclusive breastfeeding, bottle use, cariogenic diet, number of daily brushings, and use of fluoride toothpaste ≥ 1000 ppm—did not remain significant predictors in the multivariable model (all p > 0.05). This finding highlights the added value of regression modeling: while unadjusted analyses demonstrated several associations, the multivariable model clarifies that age, nationality, and breastfeeding duration are the strongest and most robust predictors of S-ECC in this population. Table 3 Multiple linear regression analysis of factors associated with S-ECC (dmft). Coefficients (B), standard errors, standardized coefficients (β), and p-values are presented. Age, nationality, and breastfeeding were significant predictors (p < 0.05) Coefficients a Model Unstandardized Coefficients Standardized Coefficients t Collinearity Statistics 95% CI (B) p B Std. Error Beta Tolerance VIF (Constant) 0.704 0.920 0.766 - 0.444 Sex -0.415 0.414 -0.036 -1.001 0.986 1.014 [-1.23 ; 0.40] 0.317 Age 0.107 0.030 0.158 3.553 0.656 1.525 [0.05 ; 0.17] < .001* Nationality -2.918 0.532 -0.247 -5.482 0.637 1.569 [-3.97 ; 1.87] < .001* Mode of delivery 0.181 0.450 0.015 0.402 0.900 1.112 [-0.70 ; 1.06] 0.688 Exclusive breastfeeding -0.270 0.615 -0.020 -0.439 0.626 1.599 [-1.48 ; 0.94] 0.661 Breastfeeding (days) 0.005 0.001 0.267 5.300 0.511 1.959 [0.00 ; 0.01] < .001* Bottle -0.040 0.441 -0.004 -0.091 0.869 1.150 [-0.91 ; 0.83] 0.928 Cariogenic diet 0.910 0.591 0.072 1.539 0.585 1.709 [-0.25 ; 2.07] 0.124 Number of brushings 0.198 0.272 0.030 0.729 0.752 1.330 [-0.34 ; 0.73] 0.466 Fluoride toothpste 0.226 0.647 0.015 0.349 0.685 1.460 [-1.04 ; 1.49] 0.727 a Dependent Variable: S-ECC (dmft); CIs computed as 𝐵±𝑡 0.975,623 ×𝑆𝐸. Model Summary: R = 0.439; R² = 0.193; Adjusted R² = 0.179; F(11, 623) = 13.529; p < 0.001. DISCUSSION This multicenter retrospective study evaluated the associations between sociodemographic, perinatal, feeding, dietary, and oral hygiene factors and the occurrence of S-ECC in children aged 0 to 3 years from Brazil and the United States. In the bivariate analyses, vaginal delivery, prolonged breastfeeding, cariogenic dietary patterns, and U.S. residency were significantly associated with higher caries prevalence. However, when all variables were considered simultaneously in a multiple regression model, only child’s age, nationality, and breastfeeding duration remained independent predictors of S-ECC. These findings emphasize the importance of employing multivariable models to disentangle overlapping effects, as several associations observed in the chi-square and Mann–Whitney tests lost statistical significance after adjustment (Eusufzai et al., 2025 ). The association between vaginal delivery and higher dmft scores is intriguing and contrasts with earlier hypotheses suggesting that vaginal birth may confer protective effects due to early colonization by beneficial oral microbes (Li et al., 2005 ; Boustedt et al., 2021 ). Our results showed that this association was evident only in unadjusted analyses, and not in the multivariable regression, suggesting that other factors—particularly socioeconomic confounders—likely play a more substantial role (Felsypremila et al., 2024 ). In certain populations, vaginal delivery is more prevalent among families of lower socioeconomic status, who may face barriers to accessing dental care, maintaining optimal oral hygiene, or affording non-cariogenic diets (Psoter et al., 2006 ; Chio et al., 2023). Prolonged breastfeeding beyond 24 months was consistently associated with increased S-ECC scores, and this relationship persisted as an independent predictor in the regression model. Although breastfeeding is well recognized for its systemic health benefits and is recommended by the World Health Organization (WHO, 2025), frequent nocturnal feeding without subsequent oral hygiene, particularly after the introduction of complementary foods, may create cariogenic conditions (Peres et al., 2017 ; Mathias et al., 2023 ; Al-Ansari, 2024). Our findings are consistent with those of Zuccon et al. (Choi et al., 2023 ), who reported that natural breastfeeding was associated with 29% more cavities than artificial feeding. Nevertheless, the literature remains inconsistent (Du et al., 2007 ; Bulut et al., 2023), highlighting the need to contextualize breastfeeding practices in relation to hygiene habits and dietary exposures. Geographic disparities were also evident. Children from the United States exhibited approximately 2.9 more carious lesions than their Brazilian counterparts, even after adjusting for other factors. This difference may reflect cultural, dietary, and healthcare system differences, including easier access to processed, sugar-rich foods and inequalities in preventive care (Centers for Disease Control and Prevention, 2019 ; Illinois Department of Public Health, 2020 ). Moreover, ethnicity and race may mediate these differences: Hispanic/Latino and Asian children in Illinois experience higher burdens of untreated caries compared with non-Hispanic White children (Illinois Department of Public Health, 2020 ), and parental beliefs and practices have been shown to influence caries outcomes in U.S. Hispanic children (Tiwari et al., 2021 ). These findings are in line with recent studies showing that psychosocial factors strongly affect oral health-related quality of life in preschool children and their parents (Araújo et al., 2025), and that maternal depression increases the risk of ECC in children living in rural settings (Camerini et al., 2025 ). As expected, older age was independently associated with higher S-ECC scores, reflecting the cumulative nature of cariogenic exposures over time (Moca et al., 2021 ). Early childhood is therefore a critical period for implementing preventive interventions (AAPD, 2020, 2024). Recent evidence further emphasizes that preventive strategies targeting expectant mothers may reduce Streptococcus mutans transmission to their children (Abdunabi et al., 2025 ), and that clinical and social consequences of early lesions—such as dental pain, bullying, and reduced OHRQoL—should not be underestimated (Fernandez et al., 2024 ; Fonseca et al., 2024 ; Tavares et al., 2025 ). This study has limitations. Its retrospective design relies on the accuracy and completeness of clinical records, and although multivariate analyses were performed, unmeasured confounders (such as parental education, income, or genetic predisposition) may have influenced the results. Additionally, the diagnosis of S-ECC was based on clinical criteria, and microbiological data were not collected. The multicenter design, including two countries with distinct cultural and healthcare contexts, may also limit external validity. Thus, the generalizability of these findings should be interpreted with caution. Despite these limitations, the inclusion of a large and diverse sample enhances the robustness of the study. A major strength of this investigation lies in its multicenter, cross-cultural design, which enabled meaningful comparisons between children from diverse socioeconomic and healthcare settings under consistent diagnostic criteria. The inclusion of a large and heterogeneous sample, combined with the application of regression models to control for potential confounders, increases the robustness and interpretability of the findings. Furthermore, the growing development of predictive models using artificial intelligence (Veseli et al., 2024 ) and advanced statistical methods (Eusufzai et al., 2025 ) reinforces the importance of studies like ours to provide reliable epidemiological data for training and validation. Clinically, the results highlight the importance of adopting a broad perspective in early risk assessments that extends beyond diet and hygiene to include birth-related variables, psychosocial determinants, and culturally influenced feeding practices. These insights can guide the development of targeted, culturally appropriate preventive strategies and reinforce the value of early-life interventions. Because S-ECC often develops early and progresses rapidly, preventive measures must be implemented from infancy, with emphasis on caregiver education, timely dental visits, dietary guidance, and oral hygiene promotion. Further prospective research is warranted to deepen understanding of these complex associations and to support effective, inclusive public health policies for early childhood oral health. CONCLUSION In conclusion, this study identified several factors associated with and predictive of S-ECC occurrence. Key predictors included vaginal delivery, prolonged breastfeeding, the advancing age of the child, residency in the United States, and the consumption of cariogenic diets. These findings suggest that the mode of delivery and dietary habits play critical roles in a child's oral health, emphasizing the need for targeted preventive measures. Declarations Conflict of interest The authors have no competing interests to declare that are relevant to the content of this article. Supplementary Material Regression Analyses on Mode of Delivery, Breastfeeding, and Diet on Severe-Early Childhood Caries. Author Contribution Conceptualization: K.F.M., L.R.F.M. and A.M.Q.Methodology: K.F.M, Prof. A.M.Q and L.R.F.M.Formal analysis and statistics: A.P.M. and K.F.M.Data collection: K.F.M., L.Y.C.L., I.C.C. and A.I.Supervision of data collection: M.J.S.B., N.L.N., A.M.Q., K.N. and S.B. Writing – original draft preparation: K.F.M.Writing – review and editing: K.F.M., S.H.M.L, A.M.Q. and L.R.F.M. Theoretical framework (breastfeeding): S.H.M.LSupervision (overall project): L.R.F.M. All authors reviewed the manuscript. Acknowledgement The authors thank the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code No 001 for funding this study, and the Information Technology teams at the University of Illinois Chicago and the University of São Paulo for providing the dental records. References Abanto J, Oliveira LB, Paiva SM, Guarnizo-Herreño C, Sampaio FC, Bönecker M. Impact of the first thousand days of life on dental caries through the life course: a transdisciplinary approach. Braz Oral Res . 2022;36:e113. Published 2022 Oct 10. doi: 10.1590/1807-3107bor-2022.vol36.0113 Abdunabi F, Kowash M, Makrygiannakis MA, Kaklamanos EG. Do clinical caries-preventive interventions applied to expectant mothers affect caries-related parameters in their children? A systematic review. Eur Arch Paediatr Dent. 2025;26(4):633–644. doi: 10.1007/s40368-025-01025-6 . Epub 2025 Apr 9. PMID: 40205160; PMCID: PMC12283861. Al-Ansari A. Breastfeeding beyond 24 months of age could be a risk for higher childhood caries experience. Evid Based Dent. 2023;24(3):116–117. Al-Sane M, Koerber A, Montero M, Baskaradoss JK, Al-Sarraf E, Arab M. Sociodemographic and behavioural determinants of early childhood caries knowledge among expectant mothers in Kuwait. Eur Arch Paediatr Dent. 2021;22(3):449–458. American Academy of Pediatric Dentistry. Caries-risk assessment and management for infants, children, and adolescents. Pediatr Dent. 2024;46(1):306–312. American Academy of Pediatric Dentistry. Policy on early childhood caries (ECC): Classifications, consequences, and preventive strategies. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2025. Angolile CM, Max BL, Mushemba J, Mashauri HL. Global increased cesarean section rates and public health implications: a call to action. Health Sci Rep. 2023;6(5):e1274. Araújo SMP, da Silva GQTL, Costa EL, Nunes AMM, Ribeiro CCC. Pathways in the association between added sugar consumption, obesity in mother-child dyads, and chronic oral disease burden in early childhood. Eur J Oral Sci. 2022;130(2):e12847. Boustedt K, Dahlgren J, Roswall J, Twetman S. Is the mode of childbirth delivery linked to the prevalence of early childhood caries? A systematic review and meta-analysis. Eur Arch Paediatr Dent. 2021;22(5):765–772. Branger B, Camelot F, Droz D, et al. Breastfeeding and early childhood caries. Review of the literature, recommendations, and prevention. Arch Pediatr. 2019;26(8):497–503. Bulut G, Kilinc G. The impact of infant feeding and oral hygiene habits on early childhood caries: a cross-sectional study. Niger J Clin Pract. 2023;26(6):810–818. Camerini AV, Silva AER, Feldens CA, Meucci RD, Prietsch SOM. Association between maternal depression and early childhood caries in rural southern Brazil: a population-based cross-sectional study. Eur Arch Paediatr Dent. 2025;26(4):791–797. doi: 10.1007/s40368-025-01047-0 . Epub 2025 May 6. PMID: 40325296. Centers for Disease Control and Prevention. Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention, and Edentulism, United States, 1999–2004 to 2011–2016. US Dept of Health and Human Services; 2019. Choi SE, White J, Mertz E, Normand SL. Analysis of race and ethnicity, socioeconomic factors, and tooth decay among US children. JAMA Netw Open. 2023;6(6):e2318425. Cuschieri S. The STROBE guidelines. Saudi J Anaesth . 2019;13(suppl 1):S31-S34. Devenish G, Mukhtar A, Begley A, et al. Early childhood feeding practices and dental caries among Australian preschoolers. Am J Clin Nutr. 2020;111(4):821–828. Du M, Li Z, Jiang H, Wang X, Feng X, Hu Y, Lin H, Wang B, Si Y, Wang C. Caries in preschool children and its risk factors in 2 provinces in China. Quintessence Int. 2007;38(2):143–151. Du MQ, Li Z, Jiang H, et al. Dental caries status and its associated factors among 3- to 5-year-old children in China: a national survey. Chin J Dent Res. 2018;21(3):167–179. Eusufzai SZ, Jamayet NB, Ahmed S, Islam MB, Ahmad WMAW, Alam MK. Development and evaluation of an early childhood caries prediction model: a deep learning-based hybrid statistical modelling approach. Eur Arch Paediatr Dent. 2025 May 12. doi: 10.1007/s40368-025-01046-1 . Epub ahead of print. PMID: 40354021. Felsypremila G, Vignesh KC, Muthu MS, Mohanapriya CD, Pricilla C, Gayathri T. Assessment of overall caries risk and mode of birth delivery in infants and children with and without ECC: a cross-sectional study. Eur Arch Paediatr Dent. 2024;25(6):869–877. doi: 10.1007/s40368-024-00946-y . Epub 2024 Sep 27. PMID: 39331348. Fernandez MS, Pauli LA, Araújo ABG, Demarco GT, Azevedo MS, da Costa VPP, Goettems ML. Dental pain in Brazilian preschool children: association with the severity of dental caries and impact on oral health-related quality of life. Eur Arch Paediatr Dent. 2024;25(4):481–490. doi: 10.1007/s40368-024-00906-6 . Epub 2024 May 18. PMID: 38761358. Fonseca PG, Neves EPS, Soares MEC, Galo R, Ramos-Jorge ML, Fernandes IB. Association between caries in anterior teeth and bullying victimization in Brazilian schoolchildren aged 6 to 10 years: a cross-sectional study. Eur Arch Paediatr Dent. 2024;25(5):715–720. doi: 10.1007/s40368-024-00933-3 . Epub 2024 Sep 13. PMID: 39266902. Foxman B, Davis E, Neiswanger K, et al. Maternal factors and risk of early childhood caries: a prospective cohort study. Community Dent Oral Epidemiol. 2023;51(5):953–965. Ge X, Lyu X, Zhou Z, et al. Caesarean-section delivery and caries risk of 3-year-old Chinese children: a retrospective cohort study. BMC Oral Health. 2023;23(1):373. Gultangvattana P, Chutabhakdikul N, Leelataweewud P, Smutkeeree A, Jirarattanasopha V. Association of temperament with oral health behaviour and caries status in Thai preschool children. Int J Paediatr Dent. 2023;33(4):412–420. Illinois Department of Public Health. Healthy Smiles Healthy Growth 2018-19: An Assessment of Oral Health Status, Beverage Consumption and Body Mass Index of Third-Grade Children in Illinois. 2020. Accessed October 3, 2023. https://dph.illinois.gov/content/dam/soi/en/web/idph/files/publications/hshg-201819-report-final-2-21-20.pdf Kotha A, Vemulapalli A, Mandapati SR, Aryal S. Prevalence, trends, and severity of early childhood caries in the United States: National Health and Nutritional Examination Survey data 2013 to 2018. Pediatr Dent .2022;44(4):261–268. Ladeira LLC, Martins SP, Costa CM, et al. Caesarean delivery and early childhood caries: estimation with marginal structural models in Brazilian pre-schoolers. Community Dent Oral Epidemiol. 2021;49(6):602–608. Li Y, Caufield PW, Dasanayake AP, Wiener HW, Vermund SH. Mode of delivery and other maternal factors influence the acquisition of Streptococcus mutans in infants. J Dent Res. 2005;84(9):806–811. Lin L, Zhao T, Qin D, Hua F, He H. The impact of mouth breathing on dentofacial development: a concise review. Front Public Health. 2022;10:929165. Mathias FB, Cademartori MG, Buffarini R, et al. Breastfeeding, consumption of ultraprocessed foods, and dental caries at 4 years of age: a birth cohort study. Int J Paediatr Dent. 2023;33(2):123–134. Moca AE, Vaida LL, Negruțiu BM, Moca RT, Todor BI. The influence of age on the development of dental caries in children. A radiographic study. J Clin Med. 2021;10(8):1702. Moimaz SAS, Borges HC, Saliba O, Garbin CA, Saliba NA. Early childhood caries: epidemiology, severity and sociobehavioural determinants. Oral Health Prev Dent. 2016;14(1):77–83. Peres KG, Chaffee BW, Feldens CA, Flores-Mir C, Moynihan P, Rugg-Gunn A. Impact of prolonged breastfeeding on dental caries: a population-based birth cohort study. Pediatrics. 2017;140(1):e20162943. Psoter WJ, Pendrys DG, Morse DE, Zhang H, Mayne ST. Associations of ethnicity/race and socioeconomic status with early childhood caries patterns. J Public Health Dent. 2006;66(1):23–29. Raj SS, Moses J, Gayathri K, Vignesh KC, Irfana A. Prevalence of early childhood caries in correlation with the mode of delivery of 8–72 months old children in Mogappair - a cross-sectional study. Int J Curr Res .2018;10:68121–68125. Saheb SAK, Najmuddin M, Nakhran AM, Mashhour NM, Moafa MI, Zangoti AM. Parents’ knowledge and attitudes toward preschool’s oral health and early childhood caries. Int J Clin Pediatr Dent .2023;16(2):371–375. Sahu P, Agrawal A, Jain D, Choudhary N. Association of early childhood caries and multiple variable factors in 3-6-year-old children. Int J Clin Pediatr Dent. 2023;16(1):42–47. Shrestha SK, Arora A, Manohar N, Ekanayake K, Foster J. Association of Breastfeeding and Early Childhood Caries: A Systematic Review and Meta-Analysis. Nutrients . 2024;16(9):1355. Published 2024 Apr 30. doi: 10.3390/nu16091355 Suresh A, Srinivasan D, Ar SE, Mahadevan S, Babu HSS. Association of early childhood caries with body mass index, dietary habits, and socioeconomic status among preschool children of Kelambakkam. Int J Clin Pediatr Dent. 2023;16(4):565–571. Tavares BS, Bendo CB, Fernandes IB, Coelho VS, Ramos-Jorge ML, Ramos-Jorge J. Dental caries in anterior teeth of babies can predict the occurrence of severe dental caries in posterior teeth: a 3-year cohort study. Eur Arch Paediatr Dent. 2025;26(2):291–298. doi: 10.1007/s40368-024-00968-6 . Epub 2024 Nov 25. PMID: 39585645. Tinanoff N, Baez RJ, Diaz Guillory C, et al. Early childhood caries epidemiology, aetiology, risk assessment, societal burden, management, education, and policy: global perspective. Int J Paediatr Dent. 2019;29(3):238–248. Tiwari T, Rai NK, Wilson AR, Gansky SA, Albino J. What can we learn from parents of caries-free and caries-active Hispanic children? JDR Clin Trans Res. 2021;6(1):47–58. Veseli E, Noor AE, Veseli K, Tovani-Palone MR. Early childhood caries detection using smartphone artificial intelligence. Eur Arch Paediatr Dent. 2024;25(2):285. doi: 10.1007/s40368-024-00871-0 . Epub 2024 Feb 25. PMID: 38403750. World Health Organization. Breastfeeding. Published 20254. Accessed October August 218, 20254. https://www.who.int/health-topics/breastfeeding World Health Organization. Oral Health Surveys: Basic Methods . 4th ed. World Health Organization; 1997. Zhou Y, Lin HC, Lo EC, Wong MC. Risk indicators for early childhood caries in 2-year-old children in southern China. Aust Dent J. 2011;56(1):33–39. Zuccon A, Pasqualini D, Zerman N, et al. Impact of breastfeeding and bottle-feeding comparison on children between 2- and 6-year-old caries development. Minerva Dent Oral Sci. 2022;71(6):339–345. Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterialEAPDSECC.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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15:33:23","extension":"html","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":144414,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7594850/v1/9c6b277054597e9b37cb85d1.html"},{"id":92010855,"identity":"d37eb7c6-e09c-472c-8351-c80e9b12c0b2","added_by":"auto","created_at":"2025-09-23 15:41:23","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":315804,"visible":true,"origin":"","legend":"\u003cp\u003eSTROBE Flow Chart of the participants included in this study.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7594850/v1/c35566a4ee9b2fd37a6a27f2.jpeg"},{"id":92010858,"identity":"159be035-e436-40bc-9879-4c4c0eb12b6c","added_by":"auto","created_at":"2025-09-23 15:41:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":228239,"visible":true,"origin":"","legend":"\u003cp\u003eStatistical differences between groups according to nationality (A), mode of delivery (B), exclusive breastfeeding (C), bottle-feeding (D), cariogenic diet (E), and use of fluoride toothpaste \u0026gt;1000 ppmF (F).\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7594850/v1/a562a4f5d084800dd6fe2365.png"},{"id":94173990,"identity":"d9a1e52f-0b73-48bd-8339-a2033831a28c","added_by":"auto","created_at":"2025-10-23 08:02:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1778063,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7594850/v1/c38da20d-3f86-4bac-9576-4b7177b469d7.pdf"},{"id":92010856,"identity":"f22c0694-e61a-474b-bb16-9fd574f7fcd7","added_by":"auto","created_at":"2025-09-23 15:41:23","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":26520,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterialEAPDSECC.docx","url":"https://assets-eu.researchsquare.com/files/rs-7594850/v1/6e15cb17a05f2d05cabf70a0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Mode of Delivery, Prolonged Breastfeeding and Diet as Predictors of Severe Early Childhood Caries: a Multicenter Study in Children Under 3 Years","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eAccording to the American Academy of Pediatric Dentistry (AAPD, 2025), Early Childhood Caries (ECC) is defined as the presence of decayed, missing (due to caries), or filled tooth surfaces in any primary tooth of a child under 72 months of age. Severe Early Childhood Caries (S-ECC) refers to smooth-surface caries in children under 3 years, or\u0026mdash;between ages 3 and 5\u0026mdash;cases meeting specific thresholds (\u0026ge;\u0026thinsp;4 affected surfaces at age 3, \u0026ge;\u0026thinsp;5 at age 4, and \u0026ge;\u0026thinsp;6 at age 5). While most studies have examined ECC in children up to 6 years of age (Boustedt et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Shrestha et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), the present investigation specifically addresses children under 3 years old. This early stage, encompassing the first 1,000 days of life, is recognized as a critical window for implementing actions and interventions that can influence long-term oral and systemic health. Focusing on this period may provide a deeper understanding of the risk factors for early caries development in this highly vulnerable population (Abanto et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe development of ECC is influenced by multiple risk factors, including dietary habits, family socioeconomic status, parental education, and oral hygiene practices. Additional determinants include demographic characteristics, parental attitudes toward dental care, a child\u0026rsquo;s temperament, and health-related behaviors such as mouth breathing (Al-Sane et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Boustedt et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Lin et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ara\u0026uacute;jo et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Sahu et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Mathias et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Suresh et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Foxman et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Saheb et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). A particular area of interest is the mode of delivery, as recent years have seen a substantial rise in cesarean section births compared with vaginal deliveries (Angolile et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe mode of delivery may have lasting implications for a child\u0026rsquo;s oral health, as studies suggest that the oral microbiota acquired during birth can differ according to delivery method. Vaginal delivery is associated with a higher prevalence of beneficial bacteria, possibly reducing the early colonization of Streptococcus mutans, a key pathogen in ECC (Li et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). Nevertheless, evidence on the relationship between delivery mode and ECC remains inconsistent. Some studies have found weak or inconclusive associations between cesarean delivery and increased ECC prevalence (Raj et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Zhou et al., 2021; Boustedt et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), whereas others reported no differences (Ladeira et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) or even suggested an increased risk associated with cesarean section (Ge et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). These inconsistencies highlight the need for further investigation, particularly in young children from diverse backgrounds.\u003c/p\u003e\u003cp\u003eThe World Health Organization (WHO, 2025) recommends exclusive breastfeeding for the first six months of life, with continued breastfeeding alongside complementary feeding until two years of age or longer. However, prolonged breastfeeding, particularly beyond 24 months and when combined with frequent cariogenic feeding and inadequate oral hygiene, has been linked to a heightened risk of S-ECC (Peres et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Mathias et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The literature remains conflicting: some studies associate extended breastfeeding with higher rates of ECC (Du et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Mathias et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Al-Ansari et al., 2024), while others report no significant correlation (Du et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Branger et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Devenish et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Bulut et al., 2023).\u003c/p\u003e\u003cp\u003eTherefore, this study aims to investigate the interrelationships between mode of delivery, dietary practices, and breastfeeding duration, and their association with S-ECC in children aged 0 to 3 years from Brazil and the United States.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eEthical aspects\u003c/h2\u003e\u003cp\u003e This study was approved by the Research Ethics Committee of the XXX as a multicenter study and by the Institutional Review Board of the University of XXX. It was conducted in accordance with the Declaration of Helsinki. Informed consent for participation and publication was obtained from all participants\u0026rsquo; legal guardians. This retrospective multicenter study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (Cuschieri, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy design\u003c/h3\u003e\n\u003cp\u003eThis was a retrospective multicenter cross-sectional study aimed at investigating whether mode of delivery, prolonged breastfeeding, and dietary habits act as risk factors for S-ECC. Data were obtained from electronic medical records, allowing standardized review of clinical information for children aged 0\u0026ndash;3 years.\u003c/p\u003e\n\u003ch3\u003eSetting\u003c/h3\u003e\n\u003cp\u003eThe study was conducted in Brazil and the United States across participating institutions (XXX). Data were collected between August 2021 and November 2023. Eligible participants were children diagnosed or not with S-ECC who underwent comprehensive dental examinations as part of their routine clinical assessments.\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eInclusion criteria:\u003c/h2\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eChildren aged 0\u0026ndash;3 years registered in the electronic medical records of XXX and XXX.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eChildren with or without a clinical diagnosis of S-ECC.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAccess to fluoridated water.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eComplete medical records containing information on mode of delivery, number of cavitated teeth, dietary habits, and breastfeeding history.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePresence of at least one fully erupted primary tooth.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eExclusion criteria:\u003c/h2\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eChildren with disabilities affecting oral hygiene or dietary practices.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eChildren with enamel defects or congenital anomalies of the dentition.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eIncomplete medical records lacking essential information (e.g., breastfeeding or diet).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eInsufficient contact with guardians to clarify data ambiguities.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eVariables\u003c/h3\u003e\n\u003cp\u003eDental caries in the primary dentition was measured using the decayed, missing, and filled teeth (dmft) index, according to WHO (2013) criteria. Decayed teeth were recorded only when lesions extended into dentin, excluding enamel-only lesions. Missing teeth were included only if extraction was attributed to caries, based on dental development and caries pattern. Filled teeth were recorded if restorations were placed due to caries, considering type, size, and condition of the dentition. The primary outcome variable was severe early childhood caries (S-ECC), defined according to WHO thresholds (WHO, 1997).\u003c/p\u003e\u003cp\u003eThe main independent variables of interest were mode of delivery (vaginal vs. cesarean), type of breastfeeding (exclusive or mixed), breastfeeding duration (in days), and dietary habits (consumption of industrialized sugar-containing foods). Potential confounders included child\u0026rsquo;s age, sex, nationality (Brazil or USA), oral hygiene practices (frequency of toothbrushing and use of toothpaste with \u0026ge;\u0026thinsp;1000 ppm fluoride), and bottle-feeding practices.\u003c/p\u003e\n\u003ch3\u003eData sources, measurement, and bias control\u003c/h3\u003e\n\u003cp\u003eDental caries examinations were conducted by calibrated dental students across all participating institutions to ensure inter-center reliability. Data were consolidated by a single investigator, based on information provided by institutional informatics teams. All variables were derived from structured assessments and included both quantitative (e.g., number of cavitated teeth) and qualitative (e.g., breastfeeding type, dietary practices) data.\u003c/p\u003e\u003cp\u003eTo minimize bias, assessment protocols were standardized across centers. Data underwent secondary review for accuracy, and guardian validation was sought when necessary. Missing data were managed through follow-up contact with families or through statistical procedures, though the proportion of missing data was low (\u0026lt;\u0026thinsp;5%).\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eStudy size\u003c/h2\u003e\u003cp\u003eSample size was estimated prior to data collection to ensure sufficient power to detect expected effects, based on reported ECC prevalence rates of 18.6% among U.S. children (Kotha et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and 17% among Brazilian children (Moimaz et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Using OpenEpi version 3.01, a minimum sample of 233 children was calculated (5% standard error). However, all available eligible records were included, yielding a final convenience sample of 700 children, thus exceeding the minimum requirement and ensuring adequate statistical power.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analyses\u003c/h2\u003e\u003cp\u003eAnalyses were performed using IBM SPSS Statistics version 21.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics (means, standard deviations, medians, interquartile ranges, and frequencies) were computed for all variables. Bivariate associations were tested using the chi-square test for categorical variables and the Mann\u0026ndash;Whitney U test for continuous variables, after confirming non-normal distributions.\u003c/p\u003e\u003cp\u003eA multiple linear regression model was built to identify independent predictors of dmft. Variables of theoretical and clinical importance were initially included: sex, age, nationality, mode of delivery (vaginal/cesarean), breastfeeding duration (days), exclusive breastfeeding, bottle-feeding, cariogenic diet, number of sugar-containing foods, frequency of toothbrushing, and use of fluoridated toothpaste (\u0026ge;\u0026thinsp;1000 ppmF). Multicollinearity was assessed through variance inflation factors (VIF) and tolerance values, with VIF\u0026thinsp;\u0026lt;\u0026thinsp;2 considered acceptable. Model assumptions were verified through residual analysis, and overall model fit was evaluated using R\u0026sup2;, adjusted R\u0026sup2;, and the F-test for significance.\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 857 records were screened for eligibility. After screening records from both participating centers and applying the eligibility criteria, 700 children were included in the final analytic sample (Brazil: n\u0026thinsp;=\u0026thinsp;268; USA: n\u0026thinsp;=\u0026thinsp;432). Records were excluded primarily for ineligibility (age outside the target range), missing key variables (e.g., dmft, mode of delivery, breastfeeding, or diet information), incomplete dental charts, or duplicate entries. The full screening and exclusion pathway is detailed in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the distribution of S-ECC according to sociodemographic, perinatal, feeding, dietary, and oral-hygiene variables, and the chi-square tests indicated several significant associations. Overall, 48.1% of the sample were female and 51.9% male, with no significant difference in S-ECC prevalence between sexes (p\u0026thinsp;=\u0026thinsp;0.071). Regarding ethnicity, most children were White (55.4%), followed by Black (14.3%), mixed-race (9.9%), and smaller proportions identified as Yellow (4.9%) or not informed (15.6%); no significant differences were observed across groups (p\u0026thinsp;=\u0026thinsp;0.399).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDescriptive data of the sample and comparison of proportions of sociodemographic data, mode of delivery, feeding, diet, and oral hygiene habits.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eS-ECC\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep*\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eSociodemographic data\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e212\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e337\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e48.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.071\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e159\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e204\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e363\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e51.85\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlack\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e0.399\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBrown\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9.85\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhite\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e150\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e238\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e388\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e55.42\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYellow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.85\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN/I\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e109\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15.57\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNationality\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBRA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e140\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e268\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e32.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e144\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e288\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e432\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e61.71\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMode of delivery\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCesarean\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e132\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e260\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e31.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVaginal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e152\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e288\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e440\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e62.85\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFeeding and diet\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eExclusive breastfeeding\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e158\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e22.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e193\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e340\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e533\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e76.14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN/I\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNight breastfeeding\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.392\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e194\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e214\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e408\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e58.28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN/I\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e147\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e196\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFeeding bottle\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e246\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e339\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e48.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e190\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e169\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e359\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e51.28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN/I\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMixed breastfeeding (bottle and breast)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e179\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e25.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.569\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12.57\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN/I\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e145\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e288\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e433\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e61.85\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCariogenic diet\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e121\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e205\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e29.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e160\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e329\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e489\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e69.85\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN/I\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.85\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHygiene habits\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHygiene after breastfeeding or bottle\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e116\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.346\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9.85\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN/I\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e184\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e331\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e515\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e73.57\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFluoride toothpaste (\u0026ge;\u0026thinsp;1000ppmF)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e127\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e183\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e371\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e554\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e79.14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN/I\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.71\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e* χ\u0026sup2; Tests, S-ECC: Severe early childhood caries, N/I: Not informed\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eNationality showed a significant association with S-ECC (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Most participants were born in the United States (61.7%), where the proportion of children with S-ECC (66.7%) was higher compared with Brazil (32.3% of the sample; 47.8% with S-ECC) \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea\u003cb\u003e).\u003c/b\u003e Mode of delivery also differed significantly (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001): vaginal delivery accounted for 62.9% of the sample and was associated with a higher prevalence of S-ECC (65.5%) compared with cesarean section (31.1% of the sample; 49.2% with S-ECC) \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e\u003cp\u003eFeeding practices further revealed significant differences. Exclusive breastfeeding was reported by 76.1% of the children and was more common among those with S-ECC (63.8%) compared with those without (48.1%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ec\u003cb\u003e)\u003c/b\u003e. In contrast, bottle-feeding was reported by 51.3% of the sample and was significantly less frequent among children with S-ECC (47.1%) than among those without (72.6%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ed\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e\u003cp\u003eDietary habits showed a strong relationship with caries. A cariogenic diet was reported by 69.9% of the children, among whom S-ECC was substantially more frequent (67.3%) compared with those without such a diet (41.0%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ee\u003cb\u003e)\u003c/b\u003e. With regard to oral-hygiene practices, the use of fluoride toothpaste containing\u0026thinsp;\u0026ge;\u0026thinsp;1000 ppmF was reported by 79.1% of the children and was significantly more common among those with S-ECC (67.0%) than among their counterparts without caries (29.1%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ef\u003cb\u003e)\u003c/b\u003e. Conversely, hygiene after breastfeeding or bottle-feeding was reported in only 9.9% of the sample and was not associated with differences in S-ECC prevalence (p\u0026thinsp;=\u0026thinsp;0.346).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIn the total sample of 700 children, 416 presented S-ECC, corresponding to a prevalence of 59.4%. According to the Mann\u0026ndash;Whitney U test \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e, children with S-ECC (n\u0026thinsp;=\u0026thinsp;416) were significantly older than those without the condition (n\u0026thinsp;=\u0026thinsp;284) (mean 23.72\u0026thinsp;\u0026plusmn;\u0026thinsp;7.13 vs. 17.81\u0026thinsp;\u0026plusmn;\u0026thinsp;9.07 months; median 24 [IQR 24\u0026ndash;24] vs. 12 [IQR 12\u0026ndash;24]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Breastfeeding duration was also longer in the S-ECC group (n\u0026thinsp;=\u0026thinsp;415; mean 452.76\u0026thinsp;\u0026plusmn;\u0026thinsp;351.98 days; median 365 [IQR 180\u0026ndash;730]) compared with children without S-ECC (n\u0026thinsp;=\u0026thinsp;269; mean 210.84\u0026thinsp;\u0026plusmn;\u0026thinsp;235.20 days; median 180 [IQR 0\u0026ndash;365]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In contrast, bottle-feeding duration was longer among children without S-ECC (n\u0026thinsp;=\u0026thinsp;114; mean 441.25\u0026thinsp;\u0026plusmn;\u0026thinsp;405.98 days; median 365 [IQR 0\u0026ndash;731]) than among those with S-ECC (n\u0026thinsp;=\u0026thinsp;127; mean 339.48\u0026thinsp;\u0026plusmn;\u0026thinsp;415.31 days; median 0 [IQR 0\u0026ndash;730]; p\u0026thinsp;=\u0026thinsp;0.015). Children with S-ECC also reported more frequent intake of sugar-containing foods (n\u0026thinsp;=\u0026thinsp;412; mean 2.24\u0026thinsp;\u0026plusmn;\u0026thinsp;2.05 episodes/day; median 2 [IQR 1\u0026ndash;3]) compared with those without S-ECC (n\u0026thinsp;=\u0026thinsp;281; mean 1.44\u0026thinsp;\u0026plusmn;\u0026thinsp;1.78 episodes/day; median 1 [IQR 0\u0026ndash;3]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Finally, toothbrushing frequency was slightly higher in the S-ECC group (n\u0026thinsp;=\u0026thinsp;389; mean 1.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.81 episodes/day; median 2 [IQR 1\u0026ndash;2]) than in children without S-ECC (n\u0026thinsp;=\u0026thinsp;277; mean 1.53\u0026thinsp;\u0026plusmn;\u0026thinsp;0.93 episodes/day; median 2 [IQR 1\u0026ndash;2]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDescriptive analysis including age, breastfeeding duration (days), bottle-feeding duration (days), daily intake of sugar-containing foods, and number of daily toothbrushing episodes, and their association with Severe Early Childhood Caries (S-ECC, assessed using the decayed, missing, and filled teeth index \u0026ndash; dmft).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003ePercentiles\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eS-ECC\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e25th\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e75th\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003ep*\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eAge (months)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e284\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e17.81 (9.070)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e12.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e24.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e416\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e23.72 (7.125)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e24.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e24.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eBreastfeeding (days)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e269\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e210.84 (235.198)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e180\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e365.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e415\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e452.76 (351.979)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e365\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e180.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e730.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eBottle (days)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e114\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e441.25 (405.983)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e365.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e731.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.015\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e127\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e339.48 (415.307)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e730.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eSugary food (daily)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e281\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.44 (1.778)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e3.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e412\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.24 (2.049)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e3.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eNumber of brush (daily)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e277\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.53 (0.934)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e389\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.82 (0.810)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e*Mann-Whitney U test, Note. Hₐ \u0026micro;\u003csub\u003eNo\u003c/sub\u003e\u0026thinsp;\u0026ne;\u0026thinsp;\u0026micro; \u003csub\u003eYes\u003c/sub\u003e\u003c/p\u003e\u003cp\u003eTo further explore the independent contribution of different factors associated with severe early childhood caries (S-ECC), measured by the dmft index, a multiple linear regression analysis was conducted \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. This approach was employed because the chi-square and Mann\u0026ndash;Whitney tests, although informative, assess each variable separately and do not account for potential interrelationships among sociodemographic, perinatal, feeding, dietary, and oral-hygiene variables. By including them simultaneously, the regression model allows for the identification of predictors that remain significantly associated with S-ECC after adjustment for confounding factors.\u003c/p\u003e\u003cp\u003eFor transparency, the complete regression outputs are provided in the Supplementary Material. The final model was statistically significant (F(11, 623)\u0026thinsp;=\u0026thinsp;13.529; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and explained 19.3% of the variance in dmft scores (R\u0026sup2; = 0.193; adjusted R\u0026sup2; = 0.179). Among the independent variables, child\u0026rsquo;s age (B\u0026thinsp;=\u0026thinsp;0.107; 95% CI: 0.05\u0026ndash;0.17; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), nationality (USA vs. Brazil; B = \u0026minus;\u0026thinsp;2.918; 95% CI: \u0026minus;\u0026thinsp;3.97 to \u0026minus;\u0026thinsp;1.87; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and breastfeeding duration in days (B\u0026thinsp;=\u0026thinsp;0.005; 95% CI: 0.00\u0026ndash;0.01; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were significantly associated with higher dmft values.\u003c/p\u003e\u003cp\u003eOther variables that appeared significant in bivariate analyses\u0026mdash;such as mode of delivery, exclusive breastfeeding, bottle use, cariogenic diet, number of daily brushings, and use of fluoride toothpaste\u0026thinsp;\u0026ge;\u0026thinsp;1000 ppm\u0026mdash;did not remain significant predictors in the multivariable model (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). This finding highlights the added value of regression modeling: while unadjusted analyses demonstrated several associations, the multivariable model clarifies that age, nationality, and breastfeeding duration are the strongest and most robust predictors of S-ECC in this population.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMultiple linear regression analysis of factors associated with S-ECC (dmft). Coefficients (B), standard errors, standardized coefficients (β), and p-values are presented. Age, nationality, and breastfeeding were significant predictors (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e\u003cp\u003eCoefficients\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eModel\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eUnstandardized Coefficients\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStandardized Coefficients\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003et\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eCollinearity Statistics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e95% CI (B)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eB\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStd. Error\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBeta\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTolerance\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eVIF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e(Constant)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.704\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.920\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.766\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.444\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.415\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.414\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.036\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-1.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.986\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.014\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e[-1.23 ; 0.40]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.317\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.107\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.030\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.158\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.553\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.656\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.525\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e[0.05 ; 0.17]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNationality\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-2.918\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.532\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.247\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-5.482\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.637\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.569\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e[-3.97 ; 1.87]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMode of delivery\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.181\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.450\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.402\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.900\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e[-0.70 ; 1.06]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.688\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eExclusive breastfeeding\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.270\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.615\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.439\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.626\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.599\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e[-1.48 ; 0.94]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.661\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBreastfeeding (days)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.005\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.267\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.511\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.959\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e[0.00 ; 0.01]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBottle\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.040\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.441\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.004\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.091\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.869\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.150\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e[-0.91 ; 0.83]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.928\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCariogenic diet\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.910\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.591\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.072\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.539\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.585\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.709\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e[-0.25 ; 2.07]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.124\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNumber of brushings\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.198\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.272\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.030\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.729\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.752\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.330\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e[-0.34 ; 0.73]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.466\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFluoride toothpste\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.226\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.647\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.349\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.685\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.460\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e[-1.04 ; 1.49]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.727\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Dependent Variable: S-ECC (dmft); CIs computed as \u0026#119861;\u0026plusmn;\u0026#119905; \u003csub\u003e0.975,623\u003c/sub\u003e\u0026times;\u0026#119878;\u0026#119864;. Model Summary: R\u0026thinsp;=\u0026thinsp;0.439; R\u0026sup2; = 0.193; Adjusted R\u0026sup2; = 0.179; F(11, 623)\u0026thinsp;=\u0026thinsp;13.529; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis multicenter retrospective study evaluated the associations between sociodemographic, perinatal, feeding, dietary, and oral hygiene factors and the occurrence of S-ECC in children aged 0 to 3 years from Brazil and the United States. In the bivariate analyses, vaginal delivery, prolonged breastfeeding, cariogenic dietary patterns, and U.S. residency were significantly associated with higher caries prevalence. However, when all variables were considered simultaneously in a multiple regression model, only child\u0026rsquo;s age, nationality, and breastfeeding duration remained independent predictors of S-ECC. These findings emphasize the importance of employing multivariable models to disentangle overlapping effects, as several associations observed in the chi-square and Mann\u0026ndash;Whitney tests lost statistical significance after adjustment (Eusufzai et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe association between vaginal delivery and higher dmft scores is intriguing and contrasts with earlier hypotheses suggesting that vaginal birth may confer protective effects due to early colonization by beneficial oral microbes (Li et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Boustedt et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Our results showed that this association was evident only in unadjusted analyses, and not in the multivariable regression, suggesting that other factors\u0026mdash;particularly socioeconomic confounders\u0026mdash;likely play a more substantial role (Felsypremila et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). In certain populations, vaginal delivery is more prevalent among families of lower socioeconomic status, who may face barriers to accessing dental care, maintaining optimal oral hygiene, or affording non-cariogenic diets (Psoter et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Chio et al., 2023).\u003c/p\u003e\u003cp\u003eProlonged breastfeeding beyond 24 months was consistently associated with increased S-ECC scores, and this relationship persisted as an independent predictor in the regression model. Although breastfeeding is well recognized for its systemic health benefits and is recommended by the World Health Organization (WHO, 2025), frequent nocturnal feeding without subsequent oral hygiene, particularly after the introduction of complementary foods, may create cariogenic conditions (Peres et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Mathias et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Al-Ansari, 2024). Our findings are consistent with those of Zuccon et al. (Choi et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), who reported that natural breastfeeding was associated with 29% more cavities than artificial feeding. Nevertheless, the literature remains inconsistent (Du et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Bulut et al., 2023), highlighting the need to contextualize breastfeeding practices in relation to hygiene habits and dietary exposures.\u003c/p\u003e\u003cp\u003eGeographic disparities were also evident. Children from the United States exhibited approximately 2.9 more carious lesions than their Brazilian counterparts, even after adjusting for other factors. This difference may reflect cultural, dietary, and healthcare system differences, including easier access to processed, sugar-rich foods and inequalities in preventive care (Centers for Disease Control and Prevention, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Illinois Department of Public Health, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Moreover, ethnicity and race may mediate these differences: Hispanic/Latino and Asian children in Illinois experience higher burdens of untreated caries compared with non-Hispanic White children (Illinois Department of Public Health, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), and parental beliefs and practices have been shown to influence caries outcomes in U.S. Hispanic children (Tiwari et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). These findings are in line with recent studies showing that psychosocial factors strongly affect oral health-related quality of life in preschool children and their parents (Ara\u0026uacute;jo et al., 2025), and that maternal depression increases the risk of ECC in children living in rural settings (Camerini et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAs expected, older age was independently associated with higher S-ECC scores, reflecting the cumulative nature of cariogenic exposures over time (Moca et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Early childhood is therefore a critical period for implementing preventive interventions (AAPD, 2020, 2024). Recent evidence further emphasizes that preventive strategies targeting expectant mothers may reduce Streptococcus mutans transmission to their children (Abdunabi et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), and that clinical and social consequences of early lesions\u0026mdash;such as dental pain, bullying, and reduced OHRQoL\u0026mdash;should not be underestimated (Fernandez et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Fonseca et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Tavares et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis study has limitations. Its retrospective design relies on the accuracy and completeness of clinical records, and although multivariate analyses were performed, unmeasured confounders (such as parental education, income, or genetic predisposition) may have influenced the results. Additionally, the diagnosis of S-ECC was based on clinical criteria, and microbiological data were not collected. The multicenter design, including two countries with distinct cultural and healthcare contexts, may also limit external validity. Thus, the generalizability of these findings should be interpreted with caution. Despite these limitations, the inclusion of a large and diverse sample enhances the robustness of the study.\u003c/p\u003e\u003cp\u003eA major strength of this investigation lies in its multicenter, cross-cultural design, which enabled meaningful comparisons between children from diverse socioeconomic and healthcare settings under consistent diagnostic criteria. The inclusion of a large and heterogeneous sample, combined with the application of regression models to control for potential confounders, increases the robustness and interpretability of the findings. Furthermore, the growing development of predictive models using artificial intelligence (Veseli et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) and advanced statistical methods (Eusufzai et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) reinforces the importance of studies like ours to provide reliable epidemiological data for training and validation. Clinically, the results highlight the importance of adopting a broad perspective in early risk assessments that extends beyond diet and hygiene to include birth-related variables, psychosocial determinants, and culturally influenced feeding practices. These insights can guide the development of targeted, culturally appropriate preventive strategies and reinforce the value of early-life interventions. Because S-ECC often develops early and progresses rapidly, preventive measures must be implemented from infancy, with emphasis on caregiver education, timely dental visits, dietary guidance, and oral hygiene promotion. Further prospective research is warranted to deepen understanding of these complex associations and to support effective, inclusive public health policies for early childhood oral health.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eIn conclusion, this study identified several factors associated with and predictive of S-ECC occurrence.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eKey predictors included vaginal delivery, prolonged breastfeeding, the advancing age of the child, residency in the United States, and the consumption of cariogenic diets.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThese findings suggest that the mode of delivery and dietary habits play critical roles in a child's oral health, emphasizing the need for targeted preventive measures.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003cp\u003eThe authors have no competing interests to declare that are relevant to the content of this article.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eSupplementary Material\u003c/h2\u003e\u003cp\u003eRegression Analyses on Mode of Delivery, Breastfeeding, and Diet on Severe-Early Childhood Caries.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization: K.F.M., L.R.F.M. and A.M.Q.Methodology: K.F.M, Prof. A.M.Q and L.R.F.M.Formal analysis and statistics: A.P.M. and K.F.M.Data collection: K.F.M., L.Y.C.L., I.C.C. and A.I.Supervision of data collection: M.J.S.B., N.L.N., A.M.Q., K.N. and S.B. Writing \u0026ndash; original draft preparation: K.F.M.Writing \u0026ndash; review and editing: K.F.M., S.H.M.L, A.M.Q. and L.R.F.M. Theoretical framework (breastfeeding): S.H.M.LSupervision (overall project): L.R.F.M. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors thank the Coordena\u0026ccedil;\u0026atilde;o de Aperfei\u0026ccedil;oamento de Pessoal de N\u0026iacute;vel Superior - Brasil (CAPES) - Finance Code No 001 for funding this study, and the Information Technology teams at the University of Illinois Chicago and the University of S\u0026atilde;o Paulo for providing the dental records.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbanto J, Oliveira LB, Paiva SM, Guarnizo-Herre\u0026ntilde;o C, Sampaio FC, B\u0026ouml;necker M. Impact of the first thousand days of life on dental caries through the life course: a transdisciplinary approach. \u003cem\u003eBraz Oral Res\u003c/em\u003e. 2022;36:e113. Published 2022 Oct 10. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1590/1807-3107bor-2022.vol36.0113\u003c/span\u003e\u003cspan address=\"10.1590/1807-3107bor-2022.vol36.0113\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbdunabi F, Kowash M, Makrygiannakis MA, Kaklamanos EG. Do clinical caries-preventive interventions applied to expectant mothers affect caries-related parameters in their children? A systematic review. Eur Arch Paediatr Dent. 2025;26(4):633\u0026ndash;644. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s40368-025-01025-6\u003c/span\u003e\u003cspan address=\"10.1007/s40368-025-01025-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2025 Apr 9. PMID: 40205160; PMCID: PMC12283861.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAl-Ansari A. Breastfeeding beyond 24 months of age could be a risk for higher childhood caries experience. \u003cem\u003eEvid Based Dent.\u003c/em\u003e 2023;24(3):116\u0026ndash;117.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAl-Sane M, Koerber A, Montero M, Baskaradoss JK, Al-Sarraf E, Arab M. Sociodemographic and behavioural determinants of early childhood caries knowledge among expectant mothers in Kuwait. \u003cem\u003eEur Arch Paediatr Dent.\u003c/em\u003e 2021;22(3):449\u0026ndash;458.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmerican Academy of Pediatric Dentistry. Caries-risk assessment and management for infants, children, and adolescents. \u003cem\u003ePediatr Dent.\u003c/em\u003e 2024;46(1):306\u0026ndash;312.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmerican Academy of Pediatric Dentistry. Policy on early childhood caries (ECC): Classifications, consequences, and preventive strategies. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAngolile CM, Max BL, Mushemba J, Mashauri HL. Global increased cesarean section rates and public health implications: a call to action. \u003cem\u003eHealth Sci Rep.\u003c/em\u003e 2023;6(5):e1274.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAra\u0026uacute;jo SMP, da Silva GQTL, Costa EL, Nunes AMM, Ribeiro CCC. Pathways in the association between added sugar consumption, obesity in mother-child dyads, and chronic oral disease burden in early childhood. \u003cem\u003eEur J Oral Sci.\u003c/em\u003e 2022;130(2):e12847.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBoustedt K, Dahlgren J, Roswall J, Twetman S. Is the mode of childbirth delivery linked to the prevalence of early childhood caries? A systematic review and meta-analysis. \u003cem\u003eEur Arch Paediatr Dent.\u003c/em\u003e 2021;22(5):765\u0026ndash;772.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBranger B, Camelot F, Droz D, et al. Breastfeeding and early childhood caries. Review of the literature, recommendations, and prevention. \u003cem\u003eArch Pediatr.\u003c/em\u003e 2019;26(8):497\u0026ndash;503.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBulut G, Kilinc G. The impact of infant feeding and oral hygiene habits on early childhood caries: a cross-sectional study. \u003cem\u003eNiger J Clin Pract.\u003c/em\u003e 2023;26(6):810\u0026ndash;818.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCamerini AV, Silva AER, Feldens CA, Meucci RD, Prietsch SOM. Association between maternal depression and early childhood caries in rural southern Brazil: a population-based cross-sectional study. Eur Arch Paediatr Dent. 2025;26(4):791\u0026ndash;797. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s40368-025-01047-0\u003c/span\u003e\u003cspan address=\"10.1007/s40368-025-01047-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2025 May 6. PMID: 40325296.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCenters for Disease Control and Prevention. Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention, and Edentulism, United States, 1999\u0026ndash;2004 to 2011\u0026ndash;2016. US Dept of Health and Human Services; 2019.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChoi SE, White J, Mertz E, Normand SL. Analysis of race and ethnicity, socioeconomic factors, and tooth decay among US children. \u003cem\u003eJAMA Netw Open.\u003c/em\u003e 2023;6(6):e2318425.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCuschieri S. The STROBE guidelines. \u003cem\u003eSaudi J Anaesth\u003c/em\u003e. 2019;13(suppl 1):S31-S34.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDevenish G, Mukhtar A, Begley A, et al. Early childhood feeding practices and dental caries among Australian preschoolers. \u003cem\u003eAm J Clin Nutr.\u003c/em\u003e 2020;111(4):821\u0026ndash;828.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDu M, Li Z, Jiang H, Wang X, Feng X, Hu Y, Lin H, Wang B, Si Y, Wang C. Caries in preschool children and its risk factors in 2 provinces in China. \u003cem\u003eQuintessence Int.\u003c/em\u003e 2007;38(2):143\u0026ndash;151.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDu MQ, Li Z, Jiang H, et al. Dental caries status and its associated factors among 3- to 5-year-old children in China: a national survey. \u003cem\u003eChin J Dent Res.\u003c/em\u003e 2018;21(3):167\u0026ndash;179.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEusufzai SZ, Jamayet NB, Ahmed S, Islam MB, Ahmad WMAW, Alam MK. Development and evaluation of an early childhood caries prediction model: a deep learning-based hybrid statistical modelling approach. Eur Arch Paediatr Dent. 2025 May 12. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s40368-025-01046-1\u003c/span\u003e\u003cspan address=\"10.1007/s40368-025-01046-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub ahead of print. PMID: 40354021.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFelsypremila G, Vignesh KC, Muthu MS, Mohanapriya CD, Pricilla C, Gayathri T. Assessment of overall caries risk and mode of birth delivery in infants and children with and without ECC: a cross-sectional study. Eur Arch Paediatr Dent. 2024;25(6):869\u0026ndash;877. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s40368-024-00946-y\u003c/span\u003e\u003cspan address=\"10.1007/s40368-024-00946-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2024 Sep 27. PMID: 39331348.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFernandez MS, Pauli LA, Ara\u0026uacute;jo ABG, Demarco GT, Azevedo MS, da Costa VPP, Goettems ML. Dental pain in Brazilian preschool children: association with the severity of dental caries and impact on oral health-related quality of life. Eur Arch Paediatr Dent. 2024;25(4):481\u0026ndash;490. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s40368-024-00906-6\u003c/span\u003e\u003cspan address=\"10.1007/s40368-024-00906-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2024 May 18. PMID: 38761358.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFonseca PG, Neves EPS, Soares MEC, Galo R, Ramos-Jorge ML, Fernandes IB. Association between caries in anterior teeth and bullying victimization in Brazilian schoolchildren aged 6 to 10 years: a cross-sectional study. Eur Arch Paediatr Dent. 2024;25(5):715\u0026ndash;720. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s40368-024-00933-3\u003c/span\u003e\u003cspan address=\"10.1007/s40368-024-00933-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2024 Sep 13. PMID: 39266902.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFoxman B, Davis E, Neiswanger K, et al. Maternal factors and risk of early childhood caries: a prospective cohort study. \u003cem\u003eCommunity Dent Oral Epidemiol.\u003c/em\u003e 2023;51(5):953\u0026ndash;965.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGe X, Lyu X, Zhou Z, et al. Caesarean-section delivery and caries risk of 3-year-old Chinese children: a retrospective cohort study. \u003cem\u003eBMC Oral Health.\u003c/em\u003e 2023;23(1):373.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGultangvattana P, Chutabhakdikul N, Leelataweewud P, Smutkeeree A, Jirarattanasopha V. Association of temperament with oral health behaviour and caries status in Thai preschool children. \u003cem\u003eInt J Paediatr Dent.\u003c/em\u003e2023;33(4):412\u0026ndash;420.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIllinois Department of Public Health. Healthy Smiles Healthy Growth 2018-19: An Assessment of Oral Health Status, Beverage Consumption and Body Mass Index of Third-Grade Children in Illinois. 2020. Accessed October 3, 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://dph.illinois.gov/content/dam/soi/en/web/idph/files/publications/hshg-201819-report-final-2-21-20.pdf\u003c/span\u003e\u003cspan address=\"https://dph.illinois.gov/content/dam/soi/en/web/idph/files/publications/hshg-201819-report-final-2-21-20.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKotha A, Vemulapalli A, Mandapati SR, Aryal S. Prevalence, trends, and severity of early childhood caries in the United States: National Health and Nutritional Examination Survey data 2013 to 2018. \u003cem\u003ePediatr Dent\u003c/em\u003e.2022;44(4):261\u0026ndash;268.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLadeira LLC, Martins SP, Costa CM, et al. Caesarean delivery and early childhood caries: estimation with marginal structural models in Brazilian pre-schoolers. \u003cem\u003eCommunity Dent Oral Epidemiol.\u003c/em\u003e 2021;49(6):602\u0026ndash;608.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi Y, Caufield PW, Dasanayake AP, Wiener HW, Vermund SH. Mode of delivery and other maternal factors influence the acquisition of Streptococcus mutans in infants. \u003cem\u003eJ Dent Res.\u003c/em\u003e 2005;84(9):806\u0026ndash;811.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLin L, Zhao T, Qin D, Hua F, He H. The impact of mouth breathing on dentofacial development: a concise review. \u003cem\u003eFront Public Health.\u003c/em\u003e 2022;10:929165.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMathias FB, Cademartori MG, Buffarini R, et al. Breastfeeding, consumption of ultraprocessed foods, and dental caries at 4 years of age: a birth cohort study. \u003cem\u003eInt J Paediatr Dent.\u003c/em\u003e 2023;33(2):123\u0026ndash;134.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoca AE, Vaida LL, Negruțiu BM, Moca RT, Todor BI. The influence of age on the development of dental caries in children. A radiographic study. \u003cem\u003eJ Clin Med.\u003c/em\u003e 2021;10(8):1702.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoimaz SAS, Borges HC, Saliba O, Garbin CA, Saliba NA. Early childhood caries: epidemiology, severity and sociobehavioural determinants. \u003cem\u003eOral Health Prev Dent.\u003c/em\u003e 2016;14(1):77\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePeres KG, Chaffee BW, Feldens CA, Flores-Mir C, Moynihan P, Rugg-Gunn A. Impact of prolonged breastfeeding on dental caries: a population-based birth cohort study. \u003cem\u003ePediatrics.\u003c/em\u003e2017;140(1):e20162943.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePsoter WJ, Pendrys DG, Morse DE, Zhang H, Mayne ST. Associations of ethnicity/race and socioeconomic status with early childhood caries patterns. \u003cem\u003eJ Public Health Dent.\u003c/em\u003e 2006;66(1):23\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRaj SS, Moses J, Gayathri K, Vignesh KC, Irfana A. Prevalence of early childhood caries in correlation with the mode of delivery of 8\u0026ndash;72 months old children in Mogappair - a cross-sectional study. \u003cem\u003eInt J Curr Res\u003c/em\u003e.2018;10:68121\u0026ndash;68125.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSaheb SAK, Najmuddin M, Nakhran AM, Mashhour NM, Moafa MI, Zangoti AM. Parents\u0026rsquo; knowledge and attitudes toward preschool\u0026rsquo;s oral health and early childhood caries. \u003cem\u003eInt J Clin Pediatr Dent\u003c/em\u003e.2023;16(2):371\u0026ndash;375.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSahu P, Agrawal A, Jain D, Choudhary N. Association of early childhood caries and multiple variable factors in 3-6-year-old children. \u003cem\u003eInt J Clin Pediatr Dent.\u003c/em\u003e 2023;16(1):42\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShrestha SK, Arora A, Manohar N, Ekanayake K, Foster J. Association of Breastfeeding and Early Childhood Caries: A Systematic Review and Meta-Analysis. \u003cem\u003eNutrients\u003c/em\u003e. 2024;16(9):1355. Published 2024 Apr 30. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/nu16091355\u003c/span\u003e\u003cspan address=\"10.3390/nu16091355\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSuresh A, Srinivasan D, Ar SE, Mahadevan S, Babu HSS. Association of early childhood caries with body mass index, dietary habits, and socioeconomic status among preschool children of Kelambakkam. \u003cem\u003eInt J Clin Pediatr Dent.\u003c/em\u003e 2023;16(4):565\u0026ndash;571.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTavares BS, Bendo CB, Fernandes IB, Coelho VS, Ramos-Jorge ML, Ramos-Jorge J. Dental caries in anterior teeth of babies can predict the occurrence of severe dental caries in posterior teeth: a 3-year cohort study. Eur Arch Paediatr Dent. 2025;26(2):291\u0026ndash;298. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s40368-024-00968-6\u003c/span\u003e\u003cspan address=\"10.1007/s40368-024-00968-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2024 Nov 25. PMID: 39585645.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTinanoff N, Baez RJ, Diaz Guillory C, et al. Early childhood caries epidemiology, aetiology, risk assessment, societal burden, management, education, and policy: global perspective. \u003cem\u003eInt J Paediatr Dent.\u003c/em\u003e2019;29(3):238\u0026ndash;248.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTiwari T, Rai NK, Wilson AR, Gansky SA, Albino J. What can we learn from parents of caries-free and caries-active Hispanic children? \u003cem\u003eJDR Clin Trans Res.\u003c/em\u003e 2021;6(1):47\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVeseli E, Noor AE, Veseli K, Tovani-Palone MR. Early childhood caries detection using smartphone artificial intelligence. Eur Arch Paediatr Dent. 2024;25(2):285. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s40368-024-00871-0\u003c/span\u003e\u003cspan address=\"10.1007/s40368-024-00871-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2024 Feb 25. PMID: 38403750.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Breastfeeding. Published 20254. Accessed October August 218, 20254. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/health-topics/breastfeeding\u003c/span\u003e\u003cspan address=\"https://www.who.int/health-topics/breastfeeding\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. \u003cem\u003eOral Health Surveys: Basic Methods\u003c/em\u003e. 4th ed. World Health Organization; 1997.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhou Y, Lin HC, Lo EC, Wong MC. Risk indicators for early childhood caries in 2-year-old children in southern China. \u003cem\u003eAust Dent J.\u003c/em\u003e 2011;56(1):33\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZuccon A, Pasqualini D, Zerman N, et al. Impact of breastfeeding and bottle-feeding comparison on children between 2- and 6-year-old caries development. \u003cem\u003eMinerva Dent Oral Sci.\u003c/em\u003e 2022;71(6):339\u0026ndash;345.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Dental caries, Breastfeeding, Child nutrition, Mode of delivery, Multicenter study","lastPublishedDoi":"10.21203/rs.3.rs-7594850/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7594850/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eThis study aimed to evaluate whether the mode of delivery, breastfeeding practices, and dietary habits were associated with severe early childhood caries (S-ECC) in children under 3 years of age from Brazil and the United States.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e This retrospective study adhered to the STROBE guidelines. Data were retrieved from electronic medical records of 700 children aged 0\u0026ndash;3 years who underwent complete oral examinations between August 2021 and November 2023. Collected variables included mode of delivery, diet, type and duration of breastfeeding, nationality, oral hygiene habits, age, and sex. Statistical analyses were conducted using chi-square tests, the Mann\u0026ndash;Whitney U test, and multiple linear regression, with a significance level set at 5%.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe overall prevalence of S-ECC was 59.4% (416/700), with 41.1% of cases from the United States and 18.2% from Brazil. Of the total sample, 51.9% were male and 48.1% female, with a mean age of 1.75 years. In bivariate analyses, vaginal delivery (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and cariogenic diet (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were significantly associated with S-ECC. In the multivariable regression model, older age (B\u0026thinsp;=\u0026thinsp;0.107, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), longer breastfeeding duration (B\u0026thinsp;=\u0026thinsp;0.005, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and U.S. nationality (B = \u0026minus;\u0026thinsp;2.918, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) remained independent predictors of higher dmft scores. Other variables were not significant.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eS-ECC was highly prevalent in this sample, affecting nearly six in ten children under 3 years of age. While vaginal delivery and cariogenic diet were associated with S-ECC in unadjusted analyses, only age, breastfeeding duration, and nationality emerged as independent predictors after adjustment. These findings underscore the multifactorial nature of S-ECC and the need for early, culturally tailored preventive strategies.\u003c/p\u003e","manuscriptTitle":"Mode of Delivery, Prolonged Breastfeeding and Diet as Predictors of Severe Early Childhood Caries: a Multicenter Study in Children Under 3 Years","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 15:33:18","doi":"10.21203/rs.3.rs-7594850/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"eb9493c3-0c8c-4165-918c-28b45dbd1eb3","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-23T07:54:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-23 15:33:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7594850","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7594850","identity":"rs-7594850","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}