Sugar Consumption and Breastfeeding Practices in Children from Mexico and Bolivia

Martínez AM¹, Chuc MG², Solórzano A³, Pérez B⁴, Delgado A⁵, Castillo A⁶, Zegarra L⁷, Jorge C⁸, Burgos R⁹, Lara E¹⁰, Ortuño J¹¹, Martínez C¹², Pimentel R¹³, Medina J¹⁴, Zelada D^15*, Villena RS¹⁵

¹Facultad de Odontología, Universidad Veracruzana, Xalapa, Veracruz, México
²Facultad de Odontología, Universidad Autónoma de Yucatán; Mérida, Yucatán, México
³Facultad de Odontología, Universidad de Guadalajara; Guadalajara, Jalisco, México
⁴Facultad de Odontología, Universidad Autónoma de Coahuila; Saltillo, Coahuila, México
⁵Facultad de Odontología, Universidad Latinoamericana; Ciudad de México, México
⁶Facultad de Odontología, Universidad Veracruzana; Orizaba, Veracruz, México
⁷Odontopediatra Caja de Salud de la Banca Privada Regional La Paz, Bolivia
⁸Odontopediatra Caja Nacional de Salud Oruro, Bolivia
⁹Odontopediatra Hospital Materno Infantil Santa Cruz, Bolivia
¹⁰Odontopediatra Caja Nacional de Salud Caminos, Regional La Paz, Bolivia
¹¹Caja Nacional de Salud Oruro, Bolivia
¹²Odontopediatra Hospital La Paz, Bolivia
¹³Odontopediatra Hospital de Achacachi, Bolivia
¹⁴Universidad San Martin de Porres – USMP, School of Medicine, Lima, Perú
¹⁵Universidad San Martin de Porres – USMP, Department of Pediatric Dentistry, Lima, Perú

*Correspondence author: Diana Zelada López, Universidad San Martin de Porres – USMP, Department of Pediatric Dentistry, Lima, Perú; Email: lzeladal@usmp.pe

Citation: Martínez AM, et al. Sugar Consumption and Breastfeeding Practices in Children from Mexico and Bolivia.  Jour Clin Med Res. 2025;6(2):1-12.

Copyright^© 2025 by Martínez AM, et al. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Table 1: Prevalence, duration and frequency of Breastfeeding (BF) in 12 to 35 months old Mexican and Bolivian children.

Table 2 shows that the introduction of sweetened beverages occurred at a mean age of 9.9 months (95% CI: 9.4-10.3). In Mexico, artificially sweetened juice (with added sugar) was the most frequently consumed (41.4%), followed by natural juice (free sugars) at 27.2%. In Bolivia, the most commonly introduced beverages were lacteous drinks/yogurt (27.2%) and tea, mate or herbal infusions (25.2%). A significant difference in the consumption of sugary beverages was found between the two countries (p < 0.001).

The mean age of introduction for sweet foods was 9.7 months (95% CI: 9.3-9.9), also showing a statistically significant difference (p < 0.001). Regarding the most commonly introduced types of sweet foods, cakes/pastries/pancakes (39.1%) and cookies (24.1%) were most frequently reported in Mexico, whereas fruit puree / baby food (49.7%) and jelly (16.7%) were more common in Bolivia.

Table 2: Age of introduction and type of sugary beverages and foods in 12 to 35 months old Mexican and Bolivian children.

When evaluating daily frequency of sweet beverage and food consumption via bottle or cup (Table 3), it was observed that bottle use was reported in 52.7% of cases in Bolivia and 36.8% in Mexico, with an overall average of 45.2%, showing significant differences (p < 0.001). The average frequency of sweet beverages consumed via bottle per day was 1.1, also showing significant differences between countries (p < 0.001). Cups were used to serve sweetened beverages on an average of 77.5% of children across both countries, with no significant differences observed. The mean frequency of sweet beverage consumption via cup was 1.3 times per day, with country-level variations: 1.4 in Bolivian children and 1.7 in Mexican children, a statistically significant difference. The frequency of daily sweet food consumption showed no significant differences. Finally, the overall mean daily frequency of sweet food and beverage consumption was 3.1 (95% CI: 2.9-3.3), with frequencies of 2 to 4 times per day being the most common, averaging 42.3% across both groups (42.9% in Bolivia and 41.8% in Mexico), with no significant differences observed. However, when evaluating consumption greater than 4 times per day, significant differences were found (p < 0.001), with 30.1% of Mexican children and 16.9% of Bolivian children falling into this category.

Table 3: Sweet beverage and food consumption in bottle or cup by 12 to 35 months old Mexican and Bolivian children.

Table 4 highlights an unusual aspect of sugar consumption involving the use of pacifiers with honey. Results showed that the use of pacifiers had an overall prevalence of 23.6% among children in both countries, with reports of use extending slightly beyond 12 months of age. Regarding the type of pacifier used, common pacifiers were more frequently reported in Bolivia (23.8%), while pacifiers containing honey inside the nipple (a manufactured product available in the Mexican market) were used by 11.5% of children in Mexico. Both cases showed statistically significant differences. It is important to note that this product, which incorporates honey within the nipple of the pacifier, has only been observed for sale in Mexico, typically found in baby product sections of pharmacies and supermarkets. The frequency of pacifier use was more prevalent during the day and also reported as a method to help children sleep at night.

Table 4: Prevalence of pacifier use and its association with products containing honey in 12 to 35 months old Mexican and Bolivian children.

Finally, Table 5 showed no correlation between breastfeeding and the delayed introduction of sugary liquids or foods.

Table 5: Mean (95%CI) age and Mean Ratio (MR) for the introduction of sugary drinks and foods according to duration of total Breastfeeding (BF).

Discussion 

According to the World Health Organization (WHO), Mexico ranks first in childhood obesity, with 44% of children aged 6 to 23 months affected [18]. Eating behaviors established during the first year of life lay the foundation for lifelong dietary habits and preferences, as well as nutrition-related health outcomes. The consumption of free sugars in the diets of infants and young children leads to early habituation to added sweet flavors, potentially causing aversion to unsweetened foods. Moreover, it promotes the development of cariogenic biofilm [19,20].

Delaying the introduction of sugary foods and beverages can be achieved through the implementation of healthy eating guidelines. Studies have found that children whose mothers received such dietary counseling had 40% lower consumption of sweets (candies, soft drinks, snacks and chocolate) during the first year of life [21].

Based on the above and considering that sugar plays a significant and direct role as a causal agent of dental caries, modulating associated factors such as the dental biofilm [19,20,22]. It is essential for healthcare professionals to be aware of children’s dietary practices when addressing Early Childhood Caries (ECC). This awareness should focus on two key aspects: the age at which sugar is introduced into the diet and the frequency of its consumption [22-24]. More recent studies also suggest that the amount of sugar consumed daily should be an additional factor taken into account when making dietary recommendations [18].

Taking this important aspect into consideration, the aim and most relevant finding of this study was to identify that the introduction of sugary foods and beverages occurs at a very early age in both countries and continues at a high frequency up to 35 months. The data obtained showed that the mean age in both countries was 9 months, which is consistent with the results reported in the 10-country regional study [17].

Regarding the types of sugary liquids introduced early, the results showed that artificially flavored juices in Mexico (41.4%) and dairy drinks or yogurt in Bolivia (27.2%) were the most prevalent, which is consistent with the findings reported by Feldens, et al., 2023. In terms of feeding methods, bottle use showed a mean prevalence of 45.2%, while the use of a cup was significantly higher, at 77.5%. Regarding solid foods, sweet porridges or purées were the most frequently consumed sweet foods in Bolivia (49.7%), similar to the data reported in Colombia (35.5%). In contrast, cakes or pastries were most commonly consumed in Mexico (39.1%), a pattern also observed in Peru (25.0%). It is worth noting that in seven Latin American countries, the most frequently reported first sweet food was cookies [17]. These foods are considered cariogenic not only because of their sugar content, but also due to their texture, which allows them to remain in the oral cavity and plaque retention areas for extended periods, even after brushing teeth, especially if oral hygiene is not performed properly [25].

Considering that a major shared risk factor for other Noncommunicable Chronic Diseases (NCDs) is the consumption of free sugars (including added sugar, sugar in honey and even natural fruit juices), the early introduction of sugar into the daily diets of very young children is concerning [18,20]. Additionally, systematic reviews have shown a strong association between higher sugar intake and increased risk of cardiovascular diseases, diabetes, obesity and dental caries [18]. Scientific evidence has led the World Health Organization (WHO) to make greater efforts to promote healthy dietary practices, advocating for the postponement of sugar introduction until after the second year of life and for the reduction of daily sugar consumption [26,27]. Regarding the types of sugary liquids introduced early, the results showed that artificially flavored juices in Mexico (41.4%) and dairy drinks or yogurt in Bolivia (27.2%) were the most prevalent, which is consistent with the findings reported by Feldens, et al., 2023. In terms of feeding methods, bottle use showed a mean prevalence of 45.2%, while the use of a cup was significantly higher, at 77.5%.

Regarding solid foods, sweet porridges or purées were the most frequently consumed sweet foods in Bolivia (49.7%), similar to the data reported in Colombia (35.5%). In contrast, cakes or pastries were most commonly consumed in Mexico (39.1%), a pattern also observed in Peru (25.0%). It is worth noting that in seven Latin American countries, the most frequently reported first sweet food was cookies [17]. These foods are considered cariogenic not only because of their sugar content, but also due to their texture, which allows them to remain in the oral cavity and plaque retention areas for extended periods, even after brushing teeth, especially if oral hygiene is not performed properly [25].

Knowledge of breastfeeding habits is another important factor to consider when assessing dietary patterns during infancy. The data show the high prevalence of breastfeeding in the studied population from both countries. This study revealed that 78.7% of children continued breastfeeding at 12 months, with Bolivia showing the highest value (83.3%), compared to Mexico (73.6%). When analyzing the data at 18 months, the average was 43.1%; however, Mexico showed a higher value (45.6%) compared to Bolivia (40.8%). Statistically significant differences were only observed between 12 and 23 months.

When comparing these results with those reported in the previous study of the 10 Latin American countries, it is evident that both Bolivia and Mexico exhibited higher values at 12 and 18 months. These values were higher than those reported at 12 months in Peru (79.2%), Costa Rica (73.3%) and Colombia (72.3%) and at 18 months in Chile (38.1%), Peru (36.4%) and Venezuela (34.8%) [17]. This information suggests that most children in the region are exposed to this important factor that promotes health from an early age [28,29]. While breastfeeding has been shown to be not only the best method of infant feeding during early childhood, it also provides multiple benefits for both the mother and the baby. The World Health Organization (WHO) and UNICEF recommend exclusive breastfeeding during the first 6 months of life, with continued breastfeeding alongside complementary foods up to 2 years of age [28]. Unlike the previously mentioned Latin American study, which found a two-month delay in the introduction of sugary foods and/or beverages among children who continued breastfeeding after 6 months, the present study did not observe this difference. However, as noted by the authors of that study, it is not possible to determine whether such a delay has any clinical impact in terms of disease [17]. It is important to highlight that this study incorporated additional questions that were not included in the study by Feldens, et al., particularly regarding nighttime breastfeeding on demand. This was considered relevant given that a high percentage of children in Latin America continue to sleep with their mothers up to 35 months of age. Considering this cultural aspect, it was deemed important to assess this practice. Birth cohort studies in various communities around the world have shown that a diet high in sugars capable of promoting cariogenic biofilm, in combination with high-frequency breastfeeding between 12 and 18 months of age, is a risk factor for early childhood caries specially when it occurs at night [10,30-33]. The results of this study showed that this practice was present in 58.5% of Bolivian children and 32.6% of Mexican children, indicating that it is a common habit in the population. It therefore requires greater attention in maternal and child health programs, with the aim of educating parents to establish proper hygiene and dietary habits from an early age. It is essential to further investigate these types of practices in future research, as their prevalence may vary depending on cultural and individual factors in each country. The implementation of effective maternal and child preventive promotion programs must be based on local data and evidence. Studies conducted in Anglo-Saxon or Asian countries may offer valuable experiences, but they do not necessarily provide protocols that are fully adaptable to the socio-cultural reality of Latin American countries. Thus, a better understanding of local dietary frequency habits is necessary to develop measures that can have a real and positive impact. Regarding breastfeeding frequency, this study found a high frequency in both countries: in Bolivia, the most common frequency was 4 to 6 times per day (54.7%), while in Mexico, more than 7 times per day was reported by 42.5% of participants. Similar findings have been reported in other Latin American countries, where over 30% of children aged 1 to 3 years breastfeed more than 7 times per day [17].

When comparing these results with those reported in the previous study of the 10 Latin American countries, it is evident that both Bolivia and Mexico exhibited higher values at 12 and 18 months. These values were higher than those reported at 12 months in Peru (79.2%), Costa Rica (73.3%) and Colombia (72.3%) and at 18 months in Chile (38.1%), Peru (36.4%) and Venezuela (34.8%) [17]. This information suggests that most children in the region are exposed to this important factor that promotes health from an early age [28,29]. While breastfeeding has been shown to be not only the best method of infant feeding during early childhood, it also provides multiple benefits for both the mother and the baby. The World Health Organization (WHO) and UNICEF recommend exclusive breastfeeding during the first 6 months of life, with continued breastfeeding alongside complementary foods up to 2 years of age [28]. Unlike the previously mentioned Latin American study, which found a two-month delay in the introduction of sugary foods and/or beverages among children who continued breastfeeding after 6 months, the present study did not observe this difference. However, as noted by the authors of that study, it is not possible to determine whether such a delay has any clinical impact in terms of disease [17]. It is important to highlight that this study incorporated additional questions that were not included in the study by Feldens, et al., particularly regarding nighttime breastfeeding on demand. This was considered relevant given that a high percentage of children in Latin America continue to sleep with their mothers up to 35 months of age. Considering this cultural aspect, it was deemed important to assess this practice. Birth cohort studies in various communities around the world have shown that a diet high in sugars capable of promoting cariogenic biofilm, in combination with high-frequency breastfeeding between 12 and 18 months of age, is a risk factor for early childhood caries specially when it occurs at night [10,30-33]. The results of this study showed that this practice was present in 58.5% of Bolivian children and 32.6% of Mexican children, indicating that it is a common habit in the population. It therefore requires greater attention in maternal and child health programs, with the aim of educating parents to establish proper hygiene and dietary habits from an early age. It is essential to further investigate these types of practices in future research, as their prevalence may vary depending on cultural and individual factors in each country. The implementation of effective maternal and child preventive promotion programs must be based on local data and evidence. Studies conducted in Anglo-Saxon or Asian countries may offer valuable experiences, but they do not necessarily provide protocols that are fully adaptable to the socio-cultural reality of Latin American countries. Thus, a better understanding of local dietary frequency habits is necessary to develop measures that can have a real and positive impact. Regarding breastfeeding frequency, this study found a high frequency in both countries: in Bolivia, the most common frequency was 4 to 6 times per day (54.7%), while in Mexico, more than 7 times per day was reported by 42.5% of participants. Similar findings have been reported in other Latin American countries, where over 30% of children aged 1 to 3 years breastfeed more than 7 times per day [17].

An additional finding in this study was related to the use of pacifiers, as it was discovered that pacifiers containing honey inside the nipple are sold on the Mexican market, specifically in the baby products section of pharmacies and supermarkets. This prompted the need to investigate the issue further, leading to the inclusion of new questions in the original questionnaire [17]. It was found that 25.5% of children in Bolivia used pacifiers, with 23.8% using conventional pacifiers. In Mexico, 21.5% of children used pacifiers, but notably, 11.5% used honey-filled pacifiers, most commonly at night for sleep. This is a significant finding that should be considered in Mexico as an industry-facilitated risk factor, highlighting the need to raise awareness among parents. The average age of pacifier use in both countries was just over 12 months, an age at which most children already have erupted incisors.

Measures and Recommendations to Reduce Sugar Intake

Strategies aimed at reducing sugar consumption at both the individual and population levels are crucial for preventing and reducing not only dental caries but also other Noncommunicable Chronic Diseases (NCDs) that may negatively impact children’s health and quality of life [34-36].

More than 40 countries have already adopted policies to increase taxes on sugar-sweetened products, with evidence showing an impact in reducing consumption [37]. A notable example is Mexico, which increased the price of sugary beverages by 10% and, after one year of implementation, saw a 12% reduction in their consumption—this effect was even more pronounced in low-income communities [38-40].

Other population-level efforts, such as informative front-of-package labeling (octagonal warnings) indicating high sugar content in products, aim to ensure consumers are aware of the nutritional content of the foods they purchase. These policies have been implemented in several countries across the region, including both Mexico and Bolivia [4,15]. The efforts are evident, but based on the results obtained, these measures are not being respected in many Latin American countries, showing that the introduction of sugar in the the diet occurs at very early ages. The findings of Feldens, et al., along with those from the present study, show that in the 12 countries in the region where data on sugar introduction was collected, the average age was 9 months far from the WHO’s recommendations to delay sugar introduction after the second year of life [38,41].

In the region’s culture, sugar is often synonymous with love and affection; it is introduced into a child’s diet by parents, grandparents, uncles and others and holds various social meanings. It is frequently used as a gesture of love, gratitude, apology or as a reward for good behavior, especially in young children. It is not only offered by family members, teachers and even pediatricians may include it. Additionally, we are constantly exposed to advertising that associates sugary foods and drinks with happiness and enjoyment, making it even more difficult for the population to maintain a healthy daily diet. However, if interventions start at a very young age, the possibility of reducing high sugar consumption and frequency is achievable.

This is demonstrated by a study conducted by the Brazilian Ministry of Health, which developed recommendations through a Food Guide for children under two years of age. The outcomes were positive, as clinical evaluations showed that delaying the introduction of sugar was associated with a reduction in the prevalence of early childhood caries [34,42].  It must be emphasized that in addition to population-level efforts and measures, individual-level actions must also be reinforced. It is crucial to emphasize the importance of training healthcare professionals in infant feeding guidelines, they should incorporate the evaluation of young patients’ diets into their care protocols, providing appropriate guidance to caregivers and, whenever possible, ensuring proper follow-up and monitoring.

Finally, it is important to emphasize that the development of this study aligns with the strategic framework of World Health Organization (WHO) initiatives, such as the Nurturing Care for Early Childhood Development campaign [43]. This campaign underscores the urgent need for governments and communities to intensify their efforts in prioritizing the health and well-being of mothers and children. The data and insights presented in this study are consistent with the objectives and priorities outlined in this line of work.

Conclusion

This study revealed an early introduction of sugary foods and beverages, as well as a high frequency of consumption during early childhood in both countries. Breastfeeding duration of more than 6 months was high, but no evidence was found that it contributed to delaying the introduction of sugary products.  It is necessary that, in addition to the current population-level efforts to reduce high sugar consumption, complementary actions at the individual level be taken by healthcare professionals, with the goal of educating and promoting healthy dietary habits from early childhood.

Conflict of Interest

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Consent to Participate

Informed consent was also obtained from each subject who participated in the study.

Financial Disclosure

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Data Availability

Data is available for the journal. Informed consents were not necessary for this paper.

Acknowledgment

We would like to thank Dr. Rafael Morales, from the Research Deparment, School of Dentistry, Universidad San Martín de Porres.

Author’s Contribution

RV conceived the project and provided training to participants from both countries; MM, MC, AS, BP, AD, AC gathered the data (Mexico); LZ, CJ, RB, EL, JO, CM, RP, gathered the data (Bolivia); DZ managed and compiled the databases of both countries; JM processed the data and created tables presented; all authors critically revised and approved the final manuscript.

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