Maternal nutrition status impacts tooth development of the fetus pre-eruptively; whereas posteruptively the impact is due to the local effects of diet [48]. See Table 2.2 for a list of effects of nutrient deficiencies on infant/child tooth development [49] and Table 2.3 for a list of vitamins and minerals recommended during pregnancy. Deficiencies of vitamins A and D along with PEM are related to a child’s risk for enamel hypoplasia and salivary gland atrophy leading to reduced ability to buffer plaque acids and increased susceptibility to dental caries [50]. Maternal intake of vitamins A, C, and D and the minerals calcium, phosphorus, fluoride iron, and iodine impact developing dentition [9] of the fetus. Frank vitamin A deficiency is rare in developed countries, but typically occurs along with PEM in developing countries [51]. Sources of vitamin A, such as fortified milk and dark yellow/orange and dark green fruits and vegetables, when limited in the maternal diet, increase risk of vitamin A deficiency. A vitamin A deficiency during pregnancy can influence an infant’s risk of impaired development of epithelial tissues, affect odontoblast differentiation, result in defective tooth enamel and dentin [52], and may reduce the extent of tooth mineralization [53]. Vitamin A deficiency in pregnancy is associated with preterm birth, IUGR, and low birth weight [54] as well as antepartum hemorrhage secondary to abruption placentae [55].

Vitamin D, calcium, and phosphorus deficiencies in pregnancy will have a substantial impact on a child’s tooth development and integrity, particularly related to enamel hypoplasia and hypomineralization and eruption of teeth. These deficiencies impact both primary and permanent teeth [12, 52]. Vitamin D deficiency occurs when dietary consumption of this nutrient is inadequate or when the pregnant woman is not exposed to adequate sunlight [56]. Hypomineralization of primary teeth related to inadequate intake of Vitamin D, calcium, and phosphorus can increase susceptibility to ECC in the infant [12, 16].

Ascorbic acid (Vitamin C) deficiency in pregnancy is associated with defective dentinal tissue development [13]. Ascorbic acid is involved in maintaining the integrity of the osteoblasts, fibroblasts, chondroblasts, and odontoblasts [13, 57] and is needed for collagen synthesis. Collagen supports the organic matrix for the deposition of calcium phosphate crystals that form during bone mineralization [13, 58]. Ascorbic acid deficiency in rats resulted in a reduction in dentin formation in laboratory studies [58]. Requirement for ascorbic acid increases during pregnancy and can be met through ingestion of fresh fruits and vegetables. Scurvy, the chronic deficiency disease of ascorbic acid, is characterized by swollen, bleeding gingiva and tooth loss. Vitamin A and ascorbic acid, through the effects of calbindin and collagen, promote mineralization and development of teeth [13].

Fluoride promotes mineralization of teeth and assists in resistance of teeth to caries by inhibiting demineralization and stimulating the remineralization of enamel of teeth [52]. Fluoride supplementation during pregnancy does not appear to be of benefit to the developing fetus [59]. The uptake of fluoride into teeth is most prominent during infancy and thereafter decreases with age [12, 52].

The fluoride content of breast milk is relatively low [9]. The primary sources for fluoride include community water supplies, some foods and beverages, and dental products [9]. A key role of fluoride is to maintain the stability of the tooth enamel [9]. Fluoride is most effective when ingested during infancy, beginning at 6 months of age, through ingestion of fluoridated community drinking water [60, 61]. In the absence of a fluoridated water supply, the child’s physician may prescribe fluoride-containing vitamin supplements (Table 2.4 ).

Dental fluorosis characterized by white opaque flecks or white or brown staining and in extreme cases, pitting of the enamel is caused by excessive fluoride ingestion. Multiple sources of fluoride especially from supplementation and toothpaste can contribute to fluorosis in the young child. Excess systemic fluoride effects on tooth structure are limited to between the ages of infancy to 14 years of age as the permanent teeth are formed within this time period [60, 61].

Intake of the minerals iron and iodine play a role in tooth development. Iodine deficiency can result in delayed tooth eruption and malocclusion and iron deficiency can impact the integrity of the tooth structure [15]. In addition to effects on dentition, both minerals are fundamental for growth and development of the fetus. A demand for increased iron during pregnancy is due to maternal blood volume expansion and the fetal iron requirements for normal development. Ingestion of adequate iron from food sources during pregnancy may be difficult for some women; therefore, iron supplementation of 30–60 mg/day is suggested [62]. Adequate iodine intake is readily achieved through use of iodized salt in the diet.

To ensure the growth, health, and development of children, adequate nutrition during infancy and early childhood is essential to avoid risk of illness, and malnutrition leading to childhood obesity, an increasing public health concern worldwide [64]. The first 2 years of life offer a critical window of opportunity for ensuring that children experience adequate and appropriate growth and development through optimal feeding practices. During the first 6 months of life, exclusive breastfeeding meets the energy and nutrient needs for most infants [65]. However, only approximately 34.8% of infants are exclusively breastfed during this period of time [66].

Breastfeeding provides short-term and long-term advantages for both child and mother [67], including protection against a range of acute and chronic diseases. See Table 2.5 [67–74]. The potential long-term advantages of breastfeeding are increasingly acknowledged as imperative [68, 69].

Obesity in later childhood and adolescence is less common among breastfed children than formula-fed children; a longer duration of breastfeeding is associated with a lower risk of obesity [75, 76]. However, breastfeeding duration of greater than 1 year is associated with decreased iron stores [77].

Children fed with commercial formulas have an increased risk of chronic diseases with an immunological basis. These include asthma and other atopic disorders [70, 71], type 1 diabetes [72], celiac disease [73], ulcerative colitis, and Crohn’s disease [74]. Published evidence links formula feeding with risks to cardiovascular health, such as changes in blood pressure [78], blood cholesterol levels [79], and resulting atherosclerosis in later adulthood [80].

After the age of 6 months, the requirements for energy and other nutrients begins to exceed what is provided by breast milk [81] and additional or complementary foods are required to meet dietary needs [82] and to promote development of masticatory efficiency and gastrointestinal tract function. Once complementary foods have been introduced, breastfeeding continues to be a major source of nutrients for the infant, providing about 50% of energy needs up to the age of 1 year [83].

Complementary foods include several categories of foods and assist in transition from a liquid-based diet (breast milk, or infant formula) to a diet including foods offering a wide range of tastes and textures. It is recommended the complementary foods in an infant’s diet be limited in the amount of salt, saturated fats and sugar, and adequate in proteins, carbohydrates, fiber, vitamins, and minerals are included [66].

In order to meet the nutritional needs of young children, complementary foods need to be nutritionally adequate, safe from food-borne pathogens or toxins, and fed in a manner that is appropriate to meet the child’s energy and nutrient needs. Potential concerns with complementary feeding include offering calorie dense and nutrient-poor foods, offering foods too frequently or not often enough, and replacing breast milk with beverages of inferior quality [60].

Guidelines from the American Academy of Pediatrics regarding the introduction of solid or complementary foods are addressed in Table 2.6 [84].

Oral health is critically important for the overall health and development of children of all ages. Approximately 42% of children (2–11 years) have had dental caries in their primary teeth and 21% of children (6–11 years) have had dental caries in their permanent teeth [95]. Caries remains one of the most common infectious diseases in children, occurring five times more than asthma [96]. Disparities exist for children from low- and moderate-income households and children of color are more likely to have caries compared to white children [95]. Children with special healthcare needs are at increased risk of caries, particularly those with cognitive disabilities, developmental or neuromuscular disorders, chronic illnesses, immune compromising diseases, certain cardiac, kidney, or liver diseases, and those who are homeless or living among migrant populations [97]. Untreated dental caries can result in serious consequences that impact self-esteem and social functioning, ability to chew and consume a varied diet, failure to gain weight, and causes for pain and discomfort. All of these circumstances can disrupt the child’s ability to function successfully in school and in society [85].

Diet and caries are closely related. Cariogenicity of a food or a constituent of a food is relative to and interdependent with multiple dietary factors, including diet composition, frequency of eating, food components of the meal, and sequencing of foods at a meal, and duration of exposure [98