BEST PRACTICES: PERINATAL AND INFANT OHC
314 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
Diet for newborns and infants
Benets of breastfeeding in a child’s rst year of life are clear
19
;
however, breastfeeding and baby bottle beyond 12 months,
especially if frequent and/or nocturnal, are associated with
early childhood caries (ECC)
20
. Allowing a child to drink from
a bottle, transportable covered cup, open cup, or box of juice
throughout the day may be harmful.
21
Importantly, frequent
consumption of free sugars (i.e., sugars added to food and
beverages and sugars naturally present in honey, syrups, fruit
juices and fruit juice concentrates) promotes the carious pro-
cess.
22
Cohort studies provide evidence that two key charac-
teristics of perinatal/infant dietary practices are critical to
prevent dental caries: the age at which sugar is introduced
to a child and the frequency of its consumption.
23,24
e
American Heart Association rec-ommends that sugar in foods
and drink be avoided by children under two years.
25
Addi-
tionally, the American Academy of Pediatrics recommends
that 100 percent fruit juice not be introduced before 12
months of age and be limited to no more than four ounces
a day for children between the ages of one and three years.
21
Dental caries risk in newborns and infants
ECC is dened as the presence of one or more decayed
(noncavitated or cavitated lesions), missing or lled (due
to caries) surfaces, in any primary tooth of a child under
six years of age.
26
ECC, like other forms of caries, is a
bacterial-mediated, sugar-driven, multifactorial, dynamic
disease that results in the phasic demineralization and
remineralization of dental hard tissues.
27
Traditional microbial
risk markers for ECC include acidogenic-aciduric bacterial
species, namely MS and Lactobacillus species.
28
MS may be
transmitted vertically from caregiver to child through salivary
contact, aected by the frequency and amount of exposure.
29
Horizontal transmission (e.g., between other members of a
family or children in daycare) also occurs.
30
Dental caries in
primary teeth may lead to chronic pain, infections, and other
morbidities. ECC has major impact on the quality of life of
children and their families and is an unnecessary health and
nancial burden to society.
27
Prevention for ECC needs to begin in infancy. Physicians,
nurses, and other health care workers may have more
opportunities to educate the parent/caregiver than dental
professionals because of the frequency of contact with the
family in the child’s rst year of life.
31
erefore, they need
to be aware of caries risk and protective factors and use this
information to promote primary care preventive messages that
include: limiting sugar intake in foods and drink; avoiding
night-time bottle feeding with milk or drinks containing
sugars; avoiding baby bottle usage and breastfeeding beyond
12 months, especially if frequent and/or nocturnal; and
having the child’s teeth brushed twice daily with a smear of
uoridated toothpaste.
32
Additionally, for children who are
at high risk for dental caries, professionally-applied uoride
varnish and dietary uoride supplements (for infants living
in nonuoridated areas) may be part of an individualized
preventive plan.
33
However, a growing number of caregivers
are hesitant about professionally-applied topical uorides.
34
Fluoride hesitancy mirrors vaccination hesitancy observed in
pediatric medicine.
35
Inaccurate information about uoride
may be shared among caregivers within online social
networks.
36
Anticipatory guidance
Anticipatory guidance in the perinatal and infant period
includes assessment of any growth and development consid-
erations that the parents should be aware of or that need
referral to the child’s medical provider.
37
Assessment of caries
risk should be considered when counselling the parents
regarding the child’s uoride exposure which includes con-
suming optimally-uoridated water, frequency of brushing
with the appropriate quantity of uoridated toothpaste, and
need for professional topical uoride applications.
38
Anticipatory
guidance during this infant period also entails oral hygiene
instruction, dietary counselling regarding sugar consumption,
frequency of periodic oral examinations
37
, and information
regarding nonnutritive habits that, if prolonged, may result
in aring of the maxillary incisor teeth, an open bite, and a
posterior crossbite.
18
Counselling regarding safety and pre-
vention of orofacial trauma would include discussions of play
objects, paciers, car seats, electrical cords, and injuries due
to falls when learning to walk.
Recommendations
1. Advise expecting and new parents regarding the
importance of their own oral health and the possi-
ble transmission of cariogenic bacteria from parent/
primary caregiver to the infant.
2. Encourage establishment of a dental home that in-
cludes medical history, dental examination, risk
assessment, and anticipatory guidance for infants by
12 months of age.
3. Provide caries preventive information regarding: high
frequency sugar consumption; brushing twice daily
with an optimal amount fluoridated toothpaste;
safety and efficacy of optimally-fluoridated commu-
nity water; and, for children at risk for dental caries,
fluoride varnish and dietary fluoride supplements
(if not consuming optimally-uoridated water).
4. Assess caries risk to facilitate the appropriate preventive
strategies as the primary dentition begins to erupt.
5. Provide information to parents regarding common
oral conditions in newborns and infants, nonnutritive
oral habits (e.g., digit sucking, use of a pacifier),
teething (including use of analgesics and avoidance
of topical anesthetics), growth and development, and
orofacial trauma (including play objects, paciers, car
seats, electric cords, and falls when learning to walk).
6. When ankyloglossia results in functional limitations
or causes symptoms, the need to surgical intervention
should be assessed on an individual basis.