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Assessing causal effects of early life‐course factors on early childhood caries in 5‐year‐old Ugandan children using directed acyclic graphs ( DAG s): A prospective cohort study
Author(s) -
Birungi Nancy,
Fadnes Lars T.,
Kasangaki Arabat,
Nankabirwa Victoria,
Okullo Isaac,
Lie Stein A.,
Tumwine James K.,
Åstrøm Anne N.
Publication year - 2017
Publication title -
community dentistry and oral epidemiology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.061
H-Index - 101
eISSN - 1600-0528
pISSN - 0301-5661
DOI - 10.1111/cdoe.12314
Subject(s) - medicine , confounding , prospective cohort study , cohort , life course approach , demography , cohort study , pediatrics , developmental psychology , psychology , sociology
Objective To estimate the effect of distal and proximal early life‐course factors on early childhood caries ( ECC ) in 5‐year‐old Ugandan children, particularly focusing on the causal effect of exclusive breast feeding ( EBF ) on ECC using directed acyclic graphs ( DAG s) for confounder selection. Methods This study had a nested prospective cohort design, focusing on 5 years of follow‐ups of caregiver‐children pairs from the PROMISE ‐ EBF trial (ClinicalTrials.gov no: NCT 00397150) conducted in 2011 in Eastern Uganda. Data were from recruitment interviews, 24‐week, 2‐year and 5‐year follow‐ups of a cohort of 417 mother‐children pairs. Trained research assistants performed interviews with caregivers in the local language and ECC was recorded under field conditions using the World Health Organization's ( WHO ) decayed missing or filled teeth (dmft) index. Early life‐course factors in terms of socio‐demographic characteristics, EBF and other feeding habits were assessed at the various follow‐ups. The outcome ( ECC ; dmft>0) was assessed at the 5‐year follow‐up. Causal diagrams as DAG s were constructed to guide the selection of confounding and collider variables to be included in or excluded from the final multivariable analysis. Negative binomial regression analyses were performed based on two comparative DAG s representing different causal models. Results Model 1 based on DAG 1, showed EBF to be a protective factor against ECC , with an IRR and 95% CI of 0.62 (0.43‐0.91). According to Model 2 based on DAG 2, EBF and having both parents living together had protective effects: the corresponding IRR s and 95% CI were 0.60 (0.41‐0.88) and 0.48 (0.25‐0.90), respectively. Conclusions Both plausible models indicated that being exclusively breastfed for 24 weeks had a protective causal effect against ECC . Further research, examining the unmeasured variables included in the DAG s is necessary to strengthen the present finding and allow stronger causal claims.