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ORAL HEALTH POLICIES: DIETARY RECOMMENDATIONS
Policy on Dietay Recoenation o Inant
C ilen an Aolecent
Latest Revision How to Cite: Aeican Acaey o Peiatic Dentity Policy on
2022 ietay ecoenation o inant c ilen an aolecent
T e Reeence Manal o Peiatic Dentity C icao Ill Aeican
Acaey o Peiatic Dentity 20229600
Purpose The causes of dental caries and obesity are multifactorial,
The American Academy of Pediatric Dentistry (AAPD) with both having significant dietary components. Beverages
recognizes its role in promoting well-balanced, low caries-risk, contribute significantly to the early diet. A 2019 consensus
and nutrient-dense diets for infants, children, adolescents, statement, Healthy Beverage Consumption in Early Childhood:
and persons with special health care needs. A healthy diet is Recommendations from Key National Health and Nutrition
essential to optimal growth and development and prevention Organizations, was developed through a collaboration of AND,
of chronic diet-related diseases such as caries, obesity, and AAPD, AAP, and AHA under the leadership of Healthy Eating
3,4
cardiovascular disease. Research, a nutrition research organization. These organiza-
tions recommend breast milk, infant formula, water, and plain
3
Methods milk for children under age five. They suggest that plain
This policy was developed by the Clinical Affairs Committee, (i.e., not flavored, sweetened, or carbonated) fluoridated water
1 2 should be introduced beginning at six months of age for
adopted in 1993 , and last revised in 2017 . This revision is
based upon a review of current dental and medical literature, children who have started solid foods to familiarize the child
including a search of the PubMed /MEDLINE database using with water as well as with drinking from a cup; the volume
® of water offered is based on the intake of other recommended
the terms: childhood, obesity, dental caries, diet, nutrition,
3,4
health education, breastfeeding, food habits, dietary guidelines, beverages. Drinking fluoridated water is a safe and effective
8
sugar, sugar-sweetened beverages, and body mass index; fields: method of reducing caries. Fluoridated water is preferred
all; limits: within the last 10 years, humans, English, clinical beverage for children one to five years of age when consumed
4
trials, and ages birth through 18. Papers for review were chosen outside of meals or snacks. The consensus statement cautioned
from the resultant lists and from hand searches. Expert and against beverages that are sources of added sugars, including
consensus opinions by experienced researchers and clinicians, flavored milks (e.g., chocolate, strawberry), or contain low-
3 3
including recommendations developed through a collaboration calorie sweeteners (LCS). Because the long-term health effects
4
of the Academy of Nutrition and Dietetics (AND), the AAPD, of consumption of LCS by children is unknown, the
the American Academy of Pediatrics (AAP), and the American statement recommended against consumption of LCS through
3
Heart Association (AHA) under the leadership of Healthy age five. In addition, it advised against a wide variety of new
Eating Research, also were considered. beverages on the market targeted to children (e.g., toddler
3
formulas) and caffeinated beverages. Plant-based/non-dairy
Background milks (e.g., almond, rice, oat) were noted to provide no
A healthy diet in early childhood is essential to supporting unique nutritional value, but unsweetened varieties may be
optimal growth and development and preventing chronic diet- useful when medically indicated (e.g., allergy or intolerance
related diseases. Experts across health care disciplines recognize to cow’s milk) or to meet specific dietary preferences (e.g.,
3,4 3,4
the importance of breastfeeding during infancy. Human vegan).
milk and breastfeeding of infants provide general health, Food and flavor preferences may be established during the
nutritional, developmental, psychological, social, economic, and early years.4,9 Establishing health dietary patterns during the
9
environmental advantages while significantly decreasing risk for a first two years of life can have lifelong health benefits. The
5
large number of acute and chronic diseases. A systematic review
of cariogenic potential of milk and infant formulas in animal ABBREVIATIONS
models found that cow’s milk and human milk are less cariogenic AAP: Aeican Acaey o Peiatic AAPD: Aeican Acaey
6
than sucrose solutions. Another systematic review concluded Peiatic Dentity AND: Acaey o Ntition an Dietetic AHA:
that children exposed to long durations of breastfeeding up to Aeican Heat Aociation BMI: oy a ine LCS: Localoie
7 eetne NHANES: National Healt an Ntition Eaination
age 12 months had reduced risk of caries. However, children Sey SCB: Sacontainin eeae SSBs: Saeetene
breastfed more than 12 months had an increased risk of caries, eeae U.S.: Unite State USDA: Unite State Deatent
and those children breastfed nocturnally or more frequently o Aiclte
7
had a further increased caries risk.
96 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
ORAL HEALTH POLICIES: DIETARY RECOMMENDATIONS
AHA recommends that children less than two years of age 19, the prevalence of obesity is an estimated 19.3 percent,
10
avoid added sugars in their diets. Sugar-sweetened beverages including 6.1 percent with severe obesity and another 16.1
21
(SSB) include any liquid (e.g., regular soda, fruit drinks, percent overweight. The obesity rate increases through
sports drinks, tea and coffee drinks, energy drinks) with added childhood and adolescence, and youth with obesity are at
sugar (e.g., fructose, corn syrup, sucrose [table sugar]).11 A increased risk for health problems (e.g., heart disease, type 2
22
longitudinal study found introduction of SSB before age one diabetes) during the teenage years and beyond.
12
was associated with obesity at age six. Sugar-containing bev- While dental caries and obesity are both significant
erages (SCB) include SSB as well as beverages in which sugar, pediatric health problems, the relationship between caries and
generally glucose or fructose, is naturally present, such as 100 anthropometric measurements is complex. Multiple systematic
percent fruit juice. In 2017, the AAP reaffirmed that 100 per- reviews have reported inconsistent and inconclusive evidence
cent juice and juice drinks have no essential role in a healthy on the relationship between caries and body mass index
23-26
diet for children and contribute to excessive calorie intake and (BMI). BMI is a simple, non-invasive means to monitor
risk of dental caries in children.13 AAP recommendations in- growth patterns and help assess the risk of obesity. Forms to
clude: juice should not be introduced to infants before one year record BMI for age and gender can be downloaded from the
of age; intake of juice should be limited to four ounces a day website of the Centers for Disease Control and Prevention at
for children one through three years of age, four to 6 ounces “https://www.cdc.gov/growthcharts/clinical_charts.htm#Set1”.27
for children four through six years of age, and eight ounces for Because of the persistent high prevalence of dental caries and
children seven through 18 years of age; toddlers should not childhood obesity, the need remains for research, policy,
be given juice in containers that foster easy consumption; and advocacy, education, and professional engagement to further
13
toddlers should not be given juice at bedtime. The mentioned advance healthy dietary practices for infants, children, and
volumes are recommended maximums, not daily requirements, adolescents.
13
and fresh fruit is preferred to fruit juice. The U.S. Department of Health and Human Services and
Unfortunately, many parents do not adhere to evidence- the U.S. Department of Agriculture (USDA) develop dietary
based dietary recommendations for their children. For example, guidelines every five years to help Americans aged two and
many infants are provided 100 percent juice and cow’s milk older make healthy food choices to help prevent chronic disease
before age one, which can increase their risk for nutrient and enjoy a healthy diet. The 2020-2025 Dietary Guidelines
14 4
(e.g., iron ) deficiencies. Nearly half of two- to five-year olds for Americans includes four overarching guidelines:
consume a SSB daily, with the prevalence increasing through- “Follow a healthy dietary pattern at every life stage.
4
out childhood. Children and adolescents in the United States Customize and enjoy nutrient-dense food and beverage
(U.S.) consumed an average of 143 calories/day from SSB choices to reflect personal preferences, cultural traditions,
between 2011-2014, and 7.3 percent of their daily energy and budgetary considerations.
intake came from SSB.15 Significant differences in beverage Focus on meeting food group needs with nutrient-dense
intake by race/ethnicity and income groups in early childhood foods and beverages, and stay within calorie limits.
4
have been noted. Limit foods and beverages higher in added sugars, satu-
Dental caries prevalence in children has been variable, but 22
remains high.16 The prevalence of dental caries (untreated and rated fat, and sodium, and limit alcoholic beverages.”
treated) in primary or permanent teeth among children aged The Dietary Guidelines for Americans also provides specific
two through 19 years has been estimated at 45.8 percent.16
The causes of dental caries involve a combination of factors quantitative recommendations including limiting:
and include diet, bacteria capable of fermenting carbohydrates, “Added sugars—Less than 10 percent of calories per
17 day starting at age two. Avoid foods and beverages with
fluoride exposure, and a susceptible host. While sugar, added sugars for those younger than age two.
especially high frequency consumption, contributes to dental
caries, a systematic study of sugar consumption and caries risk Saturated fat—Less than 10 percent of calories per day
concluded that the relationship between sugar consumption starting at age two.
and caries risk is weaker after the introduction of fluoride Sodium—Less than 2,300 milligrams per day—and even
18 22
exposure. less for children younger than age 14.”
The causes of obesity include genetic components, life-
style, and environmental variables, as well as nutritional To prevent unhealthy weight gain, the World Health
19 Organization recommends energy intake and expenditure be
factors. When consumed in excess, beverages containing sugar
3
or saturated fats can be harmful. Health initiatives in the balanced, with a goal of total fat not exceeding 30 percent of
U.S. and other countries have specifically targeted SSB in an energy intake and a shift from away from saturated fat and
effort to reduce the number of calories that children and 28
trans-fats. Limiting intake of free sugars to less than five
20
adolescents consume per day. Data from the 2017-2018 Na- percent of total energy intake per day offers additional health
tional Health and Nutrition Examination Survey (NHANES) 28
benefits. Additionally, the AHA recommends limiting con-
indicate that for children and adolescents aged two through sumption of added sugars to no more than six percent of
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 9
ORAL HEALTH POLICIES: DIETARY RECOMMENDATIONS
29
calories ; for children and adolescents, their recommended Polc stateent
limit is less than 25 grams (100 calories or approximately six The AAPD recognizes a healthy diet in early childhood is
teaspoons) of added sugar per day.10 One should note that essential to optimal growth and development and prevention
eight ounces (i.e., one measured cup) of regular soft drink of chronic diet-related diseases such as caries, obesity, and
contain approximately 26 grams of sugar; a 12 ounce can of cardiovascular disease. Through dietary and nutritional coun-
regular soda contains approximately 10 teaspoons of sugar and seling, dentists assume a significant role in preventing oral
29
has no nutritional value . disease and promoting overall health among children. The
Snacking can help a child meet daily nutritional require- AAPD especially recognizes the importance of and supports:
ments. Nearly 25 percent of children’s daily caloric intake breastfeeding of infants prior to 12 months of age to
30
may come from snacks. The AAP recommends that toddlers ensure the best possible health and developmental and
be given two to three healthy snacks daily to supply nutrients psychosocial outcomes for infants.
that the child cannot consume at mealtime; they should be the introduction of plain, fluoridated water to the
consumed at a planned time while seated with adult super- infant’s diet beginning at age six months for hydration,
31
vision. The AAP cautions against confusing snack time with to familiarize the child with the taste, and for the caries-
31
treats for fun as well as continuous/all day snacking. Fre- protective benefits of fluoride.
quent (more than three times/day) exposure to between-meal fluoridated water as the preferred beverage for children
sugar-containing snacks or beverages categorizes a child at from one to five years of age when not part of a meal or
32
high risk for dental caries. If a child is given continuous snack.
access to a bottle or cup, it should contain only water. avoiding added sugars in the diet of children younger
The USDA has established guidelines for healthy snacks than age two and minimizing exposure to sweet-tasting
30
at school. Standards for foods to qualify as a school “smart drinks and foods during early life to reduce taste prefer-
snack” include: ences for sweets.
“Be a grain product that contains 50 percent or more recommendations from the USDA for individuals aged
whole grains by weight (have a whole grain as the first two and older to consume a diet of nutrient-dense, lean
ingredient); or or low-fat foods from across five food groups (i.e., fruits,
Have as the first ingredient a fruit, a vegetable, a dairy vegetables, protein, grains, and dairy) that are prepared
product, or a protein food; or without added salt, starches, sugars, or fat.
Be a combination food that contains at least ¼ cup of limiting consumption of sugar to less than five percent
fruit and/or vegetable (for example, ¼ cup of raisins of total energy intake to reduce children’s risk of weight
with enriched pretzels); and gain and dental caries.
The food must meet the nutrient standards for calories, establishing healthy beverage consumption patterns
sodium, fats, and total sugars”.30 during the first five years to promote intake of healthy
Using 2017-2018 NHANES data, the USDA reported nutrients, limit excess intake of sugars and saturated fats,
approximately 20 percent of youth aged 12 through 19 years and initiate beneficial long-term dietary habits.
consumed more than three snacks daily.33 non-sweetened nutrient-dense snacks that supplement
Establishment of a dental home by 12 months of age meals to meet daily nutritional requirements.
provides time-critical opportunities to assess caries risk and additional health practices such as meal portion control
implement individualized caries-preventive strategies, includ- and energy balance to help prevent overweight and
ing dietary recommendations and appropriate oral hygiene obesity.
instruction, as the primary teeth begin to erupt.34 A diet that
avoids frequent consumption of liquids and foods containing Furthermore, the AAPD encourages:
sugar is essential to good oral health. The dental home also education of health professionals and the public regard-
can influence general health by instituting additional practices ing healthy beverage choices and daily sugar-consumption
related to general health promotion, disease prevention, and recommendations, as well as the sugar content of foods
screening for non-oral health related concerns. For example, and beverages.
oral health professionals can calculate and monitor BMI to dental professionals to identify children whose dietary
help identify children at risk for obesity and provide appro- patterns place them at increased risk for dental caries and
priate referral to pediatric or nutritional specialists. A 2016 obesity and, when necessary, refer for dietary counseling
survey of pediatric dentists reported that 17 percent offer from a pediatric or nutritional specialist.
childhood obesity interventions, while 94 percent offer infor- a healthy, active lifestyle so energy consumption and
mation or other interventions on the consumption of sugar energy expenditure promote general health and well-
35
sweetened beverages. Barriers to providing healthy weight being.
interventions include fear of offending the parent, appearing additional research on the benefits and effects of
judgmental, creating parent dissatisfaction, and lack of parental long-term use of low-calorie sweeteners by children.
acceptance of advice about weight management from a
35
dentist.
9 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
ORAL HEALTH POLICIES: DIETARY RECOMMENDATIONS
eerences 12. Pan L, Li R, Park S, Galuska DA, Sherry B, Freedman
1. American Academy of Pediatric Dentistry. Dietary recom- DS. A longitudinal analysis of sugar-sweetened beverage
mendations. American Academy of Pediatric Dentistry. intake in infancy and obesity at 6 years. Pediatrics 2014;
Chicago, Ill.; 1993. 134(suppl 1):S29–S35.
2. American Academy of Pediatric Dentistry. Policy on dietary 13. Heyman MB, Abrams SA. Fruit juice in infants, children,
recommendations for infants, children and adolescents. and adolescents: Current recommendations. Pediatrics
Pediatr Dent 2017;39(6):64-6. 2017;139(6):1-8.
3. Lott M, Callahan E, Welker Duffy E, Story M, Daniels 14. Ziegler EE. Consumption of cow’s milk as a cause of
S. Healthy Beverage Consumption in Early Childhood: iron deficiency in infants and toddlers. Nutr Rev 2011;
Recommendations from Key National Health and Nutri- 69(Suppl 1):S37-42.
tion Organizations. Consensus Statement. Durham, N.C.: 15. Rosinger A, Herrick K, Gahche J, Park S. Sugar-sweetened
Healthy Eating Research; 2019. Available at: “https:// beverage consumption among U.S. youth, 2011–2014.
healthyeatingresearch.org/wp-content/uploads/2019/ NCHS data brief, no 271. Hyattsville, Md.: National
09/HER-HealthyBeverage-ConsensusStatement.pdf”. Center for Health Statistics; 2017.
Accessed February 24, 2022. 16. Fleming E, Afful J. Prevalence of Total and Untreated
4. Lott M, Callahan E, Welker Duffy E, Story M, Daniels S. Dental Caries Among Youth: United States, 2015–2016.
Healthy Beverage Consumption in Early Childhood: NCHS Data Brief, no 307. Hyattsville, Md.: National
Recommendations from Key National Health and Nutri- Center for Health Statistics; 2018.
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N.C.: Healthy Eating Research, 2019. Available at: “https: management in children and adults. Institute of Medicine,
//healthyeatingresearch.org/wp-content/uploads/2019/ 2016; National Academy of Medicine, Washington, D.C.
09/HER-HealthyBeverageTechnicalReport.pdf”. Accessed Available at: “https://nam.edu/dental-caries-management-
February 24, 2022. in-children-and-adults/”. Accessed March 13, 2022.
5. American Academy of Pediatrics. Policy statement: 18. Burt BA, Pai S. Sugar consumption and caries risk: A
Breast-feeding and the use of human milk. Pediatrics systematic review. J Dent Ed 2001;65(10):1017-23.
2012;129(3):e827-41. 19. Lee A, Cardel M, Donahoo WT. Social and environmental
6. Aarthi J, Muthu S, Sujatha S. Cariogenic potential of factors influencing obesity. [Updated 2019 Oct 12]. In:
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Paediatr Dent 2013;14(5):289-300. [Internet]. South Dartmouth (MA): MDText.com, Inc.;
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8. Centers for Disease Control and Prevention. Recommen- mental interventions to reduce the consumption of
dations for using fluoride to prevent and control dental sugar-sweetened beverages and their effects on health.
caries in the United States. MMWR Recomm Rep 2001; Cochrane Database Syst Rev 2019;6(6):CD012292.
50(RR14):1-42. Available at: “https://www.ncbi.nlm.nih.gov/pmc/articles/
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from the Feeding Infants and Toddlers Study in North 21. Fryar CD, Carroll MD, Afful J. Prevalence of over-
America: What children eat, and implications for obesity weight, obesity, and severe obesity among children and
prevention. Ann Nutr Metab 2013;62(suppl 3):27-36. adolescents aged 2–19 years: United States, 1963–1965
10. Vos MB, Kaar JL, Welsh JA, et al. Added sugars and through 2017–2018. NCHS Health E-Stats; 2020.
cardiovascular disease risk in children: A scientific state- Available at: “https://www.cdc.gov/nchs/data/hestat/
ment from the American Heart Association. Circulation obesity-child-17-18/overweight-obesity-child-H.pdf”.
2017;135(19):e1017-e1034. Accessed August 18, 2022.
11. Centers for Disease Control and Prevention. Get the 22. U.S. Department of Agriculture and U.S. Department
Facts: Sugar-Sweetened Beverages and Consumption. of Health and Human Services. Dietary Guidelines for
March 11, 2021. Available at: “https://www.cdc.gov/ Americans, 2020-2025. 9th ed. December 2020.
nutrition/data-statistics/sugar-sweetened-beveragesintake. Available at: “https://www.dietaryguidelines.gov/sites/
html#:~:text=Sugar%2Dsweetened%20beverages%20 default/files/2021-03/Dietary_Guidelines_for_Americans
(SSBs),sugars%20in%20the%20American%20diet.& -2020-2025.pdf”. Accessed June 14, 2022.
text=Limiting%20the%20amount%20of%20SSB,and
%20have%20a%20healthy%20diet”. Accessed February References continued on the next page.
24, 2022.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 99

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...Oral health policies dietary recommendations policy on dietay recoenation o inant c ilen an aolecent latest revision how to cite aeican acaey peiatic dentity ietay ecoenation t e reeence manal icao ill purpose the causes of dental caries and obesity are multifactorial american academy pediatric dentistry aapd with both having significant components beverages recognizes its role in promoting well balanced low risk contribute significantly early diet a consensus nutrient dense diets for infants children adolescents statement healthy beverage consumption childhood persons special care needs is from key national nutrition essential optimal growth development prevention organizations was developed through collaboration chronic related diseases such as aap aha under leadership eating cardiovascular disease research organization these organiza tions recommend breast milk infant formula water plain methods age five they suggest that this by clinical affairs committee i not flavored sweetened o...

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