Background <p>Recent studies have explored the relationship between early feeding practices and early childhood caries (ECC), with a focus on oral hygiene, fluoride exposure, and sugary food consumption. However, the risk factors for ECC are diverse, and limited prospective studies have comprehensively examined the impact of various early feeding behaviors on ECC risk in preschoolers, including breastfeeding patterns, timing of complementary feeding, dietary diversity, sugary food intake, and micronutrient supplementation. Further research is needed to provide evidence for effective early intervention strategies to reduce ECC prevalence in preschoolers.</p> Objective <p>This study aims to examine the association between early childhood feeding practices and dental caries risk in a birth cohort of Shanghai preschoolers, with a focus on breastfeeding pattern and duration, timing and types of complementary feeding, and early dietary habits.</p> Methods <p>This analysis draws on data from the Shanghai Maternal-Child Pairs Cohort (MCPC), a well-established prospective cohort designed to examine early life exposures and child health outcomes, including 3,505 maternal-child pairs aged 3 to 5 years. Dental caries status, including presence and severity (dmft), was assessed through clinical examinations. Data on early feeding practices, including breastfeeding, complementary feeding, and dietary habits, were collected via structured parent-reported questionnaires. Statistical analyses were performed using R4.3.3 and IBM SPSS Statistics 20, with adjusted Poisson regression models to assess associations and survival analysis to explore time-dependent effects.</p> Results <p>Children with caries were more likely to have mothers with lower education levels, lower perceived family economic status, exposure to tobacco during pregnancy, and primary caregivers with dental caries. They also exhibited delayed tooth brushing initiation and behaviors such as eating after brushing and sleeping with a bottle. Our findings suggest that breastfeeding is not a risk factor for ECC. At 12 months of age, the consumption of sweets (aRR = 1.041, 95%CI: 1.020, 1.063) and sugar-sweetened beverages (aRR = 1.122, 95%CI: 1.080, 1.166) in the past 24&#xa0;h significantly increased caries risk. Early introduction of complementary foods (&lt; 6 months) also elevated the risk (aRR = 1.234, 95% CI: 1.019, 1.494). In contrast, consistent vitamin D supplementation (0–2 years) was protective (aRR = 0.980, 95% CI: 0.961, 0.998), and greater dietary diversity at 12 months was associated with lower dmft (β = -0.222, 95% CI: -0.442, -0.003). Survival analysis showed that sweet intake at 12 months shortened the caries-free survival time, whereas consistent vitamin D supplementation from birth to 2 years prolonged it.</p> Conclusion <p>Scientific early feeding strategies, including limiting sugar intake, ensuring an appropriate timing for complementary feeding, maintaining consistent vitamin D supplementation, and promoting dietary diversity, play a key role in preventing ECC.</p>