Pregnancy, Child Nutrition, and Oral Health

Energy (K cal)
Protein (g)
No increase
Note Adjustments of these recommendations are needed for women with a BMI ≤ 18 or ≥25
The 2002 Daily Recommended Intake (DRI) for protein necessary to provide adequate needs for the developing fetus and the pregnant women is 1.1 g/kg/day of body weight for a woman aged 20–39 years or an additional 25 g/day. (See DRI in the Appendices.) When evaluating the protein intake of a pregnant woman consider total protein needs and quality, as well as total energy intake. Low birth weight or preterm birth is associated with inadequate weight gain during pregnancy [45]. PEM of the mother is associated with a child’s delayed tooth eruption [46], with tooth size and with possible decreased enamel solubility, as well as salivary gland dysfunction, all of which influences a child’s caries risk [47]. Low birth weight and preterm delivery are associated with enamel hypoplasia of the child’s primary and permanent teeth [47].

Maternal Vitamin and Mineral Nutrition

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].

Table 2.2

Effects of prenatal nutrient deficiencies on tooth development [49]
Effect on tissue
Effect on caries
Human data
Protein–calorie malnutrition
Tooth eruption delayed
Tooth size
Enamel solubility decreased
Salivary gland dysfunction
Vitamin A
Decreased epithelial tissue development
Tooth morphogenesis dysfunction
Decreased odontoblast differentiation
Increased enamel hypoplasia
Vitamin D/calcium/phosphorus
Lowered plasma calcium
Hypomineralization (hypoplastic defects)
Tooth integrity compromised
Delayed eruption patterns
Ascorbic acid
Dental pulpal alterations
Odontoblastic degeneration
Aberrant dentin
Stability of enamel crystal (enamel formation)
Inhibition of demineralization
Stimulation of remineralization
Mottled enamel (excess)
Inhibition of bacterial growth
Delayed tooth eruption
Altered growth patterns
Slow growth
Tooth integrity
Salivary gland dysfunction
Table 2.3

Daily vitamin and mineral recommendations for pregnant women
Recommended intakea
Quantity in standard prenatal supplement
Some recommended food sources
Supplementation recommended?
770 RE
Fish oils, dark green leafy vegetables, and deeply colored fruits
1.4 mg
Green leafy vegetables, lean pork, soy milk, enriched whole grain breads and cereals
1.4 mg
Green vegetables, eggs, milk, meats
1.9 mg
2 mg
Wheat germ, pork, cereals, legumes
2.6 μg
Meats, poultry, fish, shellfish, milk, eggs, cheese
85 mg
50 mg
Dark green vegetables, citrus fruits
5 μg
5 μg
Fortified milk, egg yolks, fatty fish
15 mg
Polyunsaturated plant oils, wheat germ, tofu, avocado, sweet potatoes
90 mg
Leafy green vegetables, cabbage, cheese
600 μg
400–600 μg
Dark-green leafy vegetables, beans, peas, lentils
18 mg NE
Peanut butter, lean ground beef, chicken, tuna, shrimp
27 mg
30 mg
Red meats, spinach, broccoli, tofu, shrimp, iron-fortified cereals
1000–1300 mg
250 mg
Dairy products including milk, yogurt and cheese; leafy vegetables; almonds; calcium-fortified foods
700–1250 mg
All animal foods (meats, fish, poultry, eggs, milk)
11–12 mg
15 mg
Lentils, shrimp, crab, turkey, pork, lean ground beef, eggs, tofu
a Source Institute of Medicine [12, 15, 63]
bSupplementation is recommended if food high in calcium are not consumed
cBoth iron and copper compete with zinc at absorption sites; therefore, zinc supplementation is recommended when elemental iron supplementation exceeds 60 mg/d
RE Retinol equivalents; NE Niacin equivalents
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 ).

Table 2.4

Recommended dietary fluoride (F) supplementation for infants and children based on levels in fluoridated water [60, 61]
Fluoride content of water supply
<0.3 ppm F
0.3–0.6 ppm F
>0.6 ppm F
Birth-6 months
6 month–3 years
0.25 mg
3–6 years
0.50 mg
0.25 mg
6 year up to at least 16 years
1.00 mg
0.50 mg
Note: ppm = part per million
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.

Infant and Early Childhood Feeding Practices and Oral Health

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 [6774]. The potential long-term advantages of breastfeeding are increasingly acknowledged as imperative [68, 69].

Table 2.5

Advantages of breastfeeding for infants and mothers [6774]
Advantages of breastfeeding to infant
Advantages of breastfeeding to mother
Short-term advantages
Lower morbidity of diarrheal, respiratory, and allergic diseases, lower risk of otitis media and ear infections, and development of type 1 diabetes
Reduced post-partum bleeding
Long-term advantages (adulthood)
Associated with lower mean serum cholesterol, systolic and diastolic blood pressure, overweight and obesity risk, type 2 diabetes
Lower risk of ovarian and breast cancer and development of rheumatoid arthritis
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].

Table 2.6

Guidelines for introducing solid or complementary foods into an infant’s diet [84]
Child should be able to sit upright with good head control
Child should reach for food and seem eager to be fed
Child should be able to move the food from a spoon to his/her throat
Generally infants need to have doubled their birth weight or weigh about 13 pounds to be ready for solid foods
Introduction of foods has typically been by tradition with single grain cereals introduced first, followed by vegetables then fruits although no evidence exists that demonstrates an advantage of one food over another when introducing
Provide one new food at a time and wait 2–3 days before introducing another new food to allow assessment of allergy symptoms
Within a few months of introducing foods to the child’s diet, the diet should contain breast milk or infant formula, cereals, vegetables, fruits, meats, eggs, and fish

Health Consequences of Early Childhood Caries

The combined presence of cariogenic microorganisms, fermentable carbohydrate, and a susceptible tooth and host initiate the infectious and transmissible disease known as dental caries. Although preventable and reversible, ECC is the most common chronic infectious disease of childhood. When left untreated it results in pain, bacteremia, high treatment cost, reduced growth and development, speech disorders, and premature tooth loss. Consequently, ability to bite and chew can be compromised and children may exhibit loss of self-esteem, and harm to permanent dentition [85, 86]. ECC may reduce a child’s ability to consume a varied diet.
Dietary data from the Healthy Eating Index for 2- to 5-year-old children found those with the best dietary practices were 44% less likely to display severe ECC compared with children with less desirable eating habits [87]. Increased consumption of readily available sugar-sweetened beverages, candies, chips, and cookies adds excessive calories to the diet and increases the risk of caries. Inadequate intake of fruits and vegetables deprives the child of nutrients essential to growth and development [88, 89].
Extensive ECC may be associated with low weight for age; Acs et al. [90] found a significant difference in baseline weights between preschool children with ECC and those who were caries free. In addition, those with ECC met failure to thrive weight criteria at baseline measurement. Children treated for ECC experienced significant increases in their age-adjusted percentile weights (p < 0.01) [90]. Since ECC is associated with underlying nutritional deficiencies in the perinatal period [91], it seems probable that as the disease progresses, developmental eating behaviors and nutritional status are vulnerable.

Recommended Infant and Early Childhood Feeding Practices to Promote Oral Health

Breast milk or formula is supplemented and partially replaced with complementary foods as the infant is developmentally ready (refer to Table 2.6). The introduction of pureed and solid foods is recommended to coincide with developmental, cognitive, and physiological needs. Feeding guidelines promote adequate nutritional intake to support continued growth and development as well as oral health for infants and young children (Table 2.7) [9294].

Table 2.7

Recommended dietary guidelines and practices for oral health promotion of infants and young children [9294]
Birth to 6 months
•Whether breast- or bottle-feeding is the method of choice, infant feeding schedules should encourage routine consumption of milk rather than on-demand feeding
•Discourage bedtime bottles and nocturnal feeding after eruption of first tooth
•Diminish transmission of bacteria from caregiver to infant by wiping the gums after feedings and implementing oral hygiene when the first tooth erupts
•Promote introduction of water in bottles as appropriate but not until routine feeding is well established
•Instruct mothers to avoid introduction of food until the infant doubles the birth weight or weighs at least 13 lbs or reaches 6 months of age
6–12 months
•Promote weaning from the bottle in combination with the introduction of a cup and spoon
•Promote introduction of food to encourage self-feeding
1–3 year
•Stress the value of mealtime and snacks and the importance of variety and moderation. Offer no more that 1 cup/d of fruit juices and only at meals and avoid all carbonated beverages during the first 30 months of life

School-Age Children and Oral Health

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

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Nov 6, 2015 | Posted by in General Dentistry | Comments Off on Pregnancy, Child Nutrition, and Oral Health
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