: Nutritional Requirements During Growth and Development and Eating Habits Affecting Oral Health

MULTIPLE CHOICE

1. The birth weight of an infant doubles in 3 months, and it has quadrupled by 1 year of age. Length or height increases by 50% by year of age.

a.
Both statements are true.
b.
Both statements are false.
c.
The first statement is true; the second is false.
d.
The first statement is false; the second is true.

ANS: D

The birth weight doubles in 4 months, and by 1 year of age it has usually tripled. Length or height increases 50% by 1 year of age. This means that a 5-pound newborn will weigh 10 pounds at 4 months and 15 pounds at 1 year. This information is vital because growth is the definitive test of health and is used as the most sensitive and specific indicator nutritional status.

REF: p. 266

2. Human breast milk provides distinct advantages over commercially produced formulas because the infant’s system is not fully developed.

a.
Both the statement and the reason are correct and related.
b.
Both the statement and the reason are correct but are not related.
c.
The statement is correct, but the reason is not correct.
d.
The statement is not correct, but the reason is correct.
e.
Neither the statement nor the reason is correct.

ANS: A

The American Academy of Allergy, Asthma and Immunology (AAAAI) strongly recommends exclusive breastfeeding for at least 4 months to reduce potential for long-term health consequences. Specific protein fractions synthesized in breast tissue promote colonies of healthy bacteria in the gastrointestinal tract that aid nutrient absorption and help to protect infants from infections and illness.

REF: p. 267

3. Each of the following is true of human breast milk except one. Which one is the exception?

a.
It is normally thin with a slightly bluish color.
b.
It contains long-chain fatty acids.
c.
It is low in cholesterol.
d.
Fat digestion cannot occur for several months after birth.
e.
Although iron content is low, it is utilized efficiently.

ANS: C

Human breast milk, normally thin and slightly bluish, contains significant long-chain fatty acids and is relatively high in cholesterol. The enzyme lipase within breast milk aids in digestion of fat from birth. Note that the low mineral content of human milk is ideal for the infant’s immature kidneys. An example is iron; the content is low, but it is utilized efficiently.

REF: p. 267

4. Human breast milk contains omega-3 and omega-6 fatty acids. Compared with cow’s milk, human milk is low in lactose and relatively high in protein.

a.
Both statements are true.
b.
Both statements are false.
c.
The first statement is true; the second is false.
d.
The first statement is false; the second is true.

ANS: C

Docosahexaenoic acid and arachidonic acid are omega-3 and omega-6 fatty acids, respectively. Compared with cow’s milk, human milk is high in lactose and relatively low in protein. Note that lipase, an enzyme present in breast milk, breaks down the disaccharide sugar, lactose.

REF: p. 267

5. Iron-rich food or a daily low-dose oral iron supplement should be initiated at what age?

a.
2 to 3 months
b.
4 to 6 months
c.
5 to 6 months
d.
6 months

ANS: B

Because of the high bioavailability of iron, additional sources of iron are unnecessary during the first 4 to 6 months for breastfed infants. Supplemental foods during that time can reduce iron absorption. Note that although the iron content of breast milk is low, inherent compounds in human milk promote efficient iron utilization.

REF: p. 267

6. Because of increasing cases of fluorosis, low levels of fluoride are added to commercial infant formula. Breast milk provides low levels of fluoride.

a.
Both statements are true.
b.
Both statements are false.
c.
The first statement is true; the second is false.
d.
The first statement is false; the second is true.

ANS: D

Because of increasing cases of fluorosis, no fluoride is added to infant formulas. However, they contain a small amount of inherent fluoride as a result of some of the ingredients and processing. Breast milk provides approximately 0.01 mg/day of fluoride, regardless of drinking water and maternal plasma levels. Despite this low level, dental caries does not seem to increase. The American Dental Association and American Academy of Pediatric Dentistry recommend delaying fluoride supplements for all infants until 6 months of age.

REF: p. 267

7. What percentage of infants and young children are affected by cow’s milk allergy?

a.
2% to 3%
b.
5%
c.
5% to 10%
d.
18% to 20%

ANS: A

Cow’s milk allergy, the most common allergy, affects 2% to 3% of infants and young children. Many different formulas are available as substitutes when an infant does not tolerate a cow’s milk protein-based formula. The American Academy of Allergy, Asthma and Immunology (AAAAI) recommends hydrolyzed protein (protein broken down into amino acids) formula for infants at increased risk of allergic disease (family history). Soy protein–based formulas are the most commonly used substitute, accounting for nearly 25% of the formula market.

REF: p. 268

8. Infants who are given artificial infant milk tend to weigh less than breastfed infants. No artificial infant milk can match the benefits of breast milk.

a.
Both statements are true.
b.
Both statements are false.
c.
The first statement is true; the second is false.
d.
The first statement is false; the second is true.

ANS: D

Infants who are fed artificial infant milk tend to weight more than breastfed infants. It is thought this puts them at risk for obesity later in life, but more research is needed to confirm this association. Although artificial formulas are constantly being modified to duplicate components of human milk more closely, no formula can match the benefits of breast milk.

REF: p. 267

9. An appropriate caloric concentration of infant formula that provides adequate nutrients for full-term infants is approximately _____ kcal/oz.

a.
10
b.
20
c.
25
d.
30

ANS: B

For full-term infants, an appropriate caloric concentration to provide an adequate supply of nutrients is 20 kcal per ounce of body weight. The American Academy of Pediatrics has established guidelines for formulas with respect to electrolyte, mineral, and vitamin content. Adequate amounts of electrolyte, mineral, and vitamin (except for fluoride and iron) are furnished if the infant receives 150 to 180 mL/kg per day of a commercial formula with iron.

REF: p. 268

10. Well-conducted trials support probiotics in infant formulas for their role in preventing:

a.
allergic diseases.
b.
food reactions.
c.
anemia.
d.
necrotizing enterocolitis.

ANS: D

Well-conducted clinical trials document that probiotics show promise at preventing necrotizing enterocolitis. This condition occurs in neonates with the development of cellular dead patches in the intestines. Digestion and absorption are disrupted. Although much research has been performed, there is insufficient evidence to recommend the addition of probiotics for prevention of allergic diseases, food reactions, or anemia.

REF: p. 268

11. Soy protein–based formulas are considered superior to cow’s milk protein–based formulas for managing infantile colic, fussiness, and prevention of atopic disease. Comparisons of various commercial formulas with human breast milk consistently indicate that breastfed infants had a slight advantage offer all other types of artificial formulas.

a.
Both statements are true.
b.
Both statements are false.
c.
The first statement is true; the second is false.
d.
The first statement is false; the second is true.

ANS: D

The effects of cow’s milk and soy-based formulas on infantile colic, fussiness, or prevention of atopic disease are similar. Comparisons of various formula types with breast milk indicated that breastfed infants had a slight advantage over all other types of artificial infant formulas.

REF: p. 268

12. Soy protein–based formulas are appropriate for each of the following except one. Which one is the exception?

a.
Galactosemia
b.
Hereditary lactase deficiency
c.
Vegetarian dietary preference
d.
Cow’s milk protein allergy

ANS: D

For infants with cow’s milk protein allergy, hydrolyzed protein formula should be considered. Note that these more expensive formulations have not shown any benefits over intact cow protein formulas for healthy, term infants. The remaining selections represent conditions or situations appropriate selection of soy protein–based formula.

REF: p. 268

13. Each of the following is true except one. Which one is the exception?

a.
Infant formulas should be discontinued at approximately 1 year of age.
b.
Vitamin D–fortified whole milk should not be provided until 2 years.
c.
Low-fat milk is not recommended for children younger than 2 years.
d.
Special toddler formulas are available, but are unnecessary.

ANS: B

After discontinuing breast feeding or infant formulas, vitamin D–fortified whole milk should be provided until age 2. The remaining selections are true. Note also that lactose-free and reduced lactose-containing cow’s milk formulas are available and could be used for circumstances in which elimination or a reduction in lactose is required.

REF: p. 268

14. To help prevent early childhood caries (ECC), the dental hygienist should recommend he infant:

a.
not be given nighttime bottles.
b.
drink pasteurized skim milk.
c.
eat iron-rich foods.
d.
drink fruit juice.

ANS: A

All expectant parents should be educated about techniques for avoiding early childhood caries, including avoidance of using a bottle or sippy cup as a pacifier at bedtime, naptime, or throughout the day. Fruit juice provides no nutritional benefit for infants younger than 6 months and is highly cariogenic. To decrease the risk of dental caries, fruit juice should not be given in bottles or sippy cups. After weaning from breast or bottle feeding, babies should be given whole vitamin D–fortified milk. All children require iron, with the need increasing after 6 months.

REF: p. 271

15. A mother’s food choices during pregnancy will affect her child’s health, but have little bearing on later preferences because flavors from the mother’s diet rarely transmit through amniotic fluid.

ANS: E

Flavors from the mother’s diet are transmitted through amniotic fluid and mother’s milk. A mother’s food choices, particularly for fruits and vegetables, influence later preferences and food behaviors.

REF: p. 270

16. Each of the following is true of iron requirements except one. Which one is the exception?

a.
Healthy, full-term infants require minimal iron during the first 6 months.
b.
Breastfed infants do not require iron supplementation until 4 to 6 months.
c.
Iron supplementation is recommended after 4 months for formula-fed, healthy infants.
d.
Preterm infants should receive iron supplements after 6 months.
e.
Iron supplementation is usually given as liquid drops.

ANS: D

Preterm infants should receive iron supplementation after 2 months. The basis for these recommendations is that during the first 6 months of a full-term infant’s life, only minimal amounts of iron are required. This guideline varies depending on the health of the infant and the type of feeding. Note that a premature infant needs iron supplementation before breastfed or formula-fed healthy infants do.

REF: p. 270

17. Fluoride supplementation is recommended for all infants older than 6 months and children because this mineral increases the strength and acid resistance of developing tooth enamel.

ANS: D

Before fluoride supplementation is prescribed, the American Association of Pediatric Dentistry (AAPD) recommends a caries risk assessment and an evaluation of dietary sources of fluoride, including fluoridated water. Vitamin supplements containing fluoride can be prescribed by a healthcare provider or dentist. The reason correctly states that fluoride increases strength and acid resistance of developing enamel.

REF: p. 270

18. Maxillary molars are affected first by early childhood caries. Artificial infant milk is more cariogenic than human breast milk.

a.
Both statements are true.
b.
Both statements are false.
c.
The first statement is true; the second is false.
d.
The first statement is false; the second is true.

ANS: B

Because the disease state follows the eruption pattern, maxillary incisors are affected first, followed by the molars and then the canines. Breast milk and artificial infant milk are equally cariogenic.

REF: p. 272

19. Infants both with cleft palates are high risk of developmental delays. While holding the infant in the sitting position during feeding may be easier, it results in nasal regurgitation.

a.
Both statements are true.
b.
Both statements are false.
c.
The first statement is true; the second is false.
d.
The first statement is false; the second is true.

ANS: C

Holding the infant in the sitting position is often recommended to minimize feeding difficulties such as nasal regurgitation, excessive air intake, and frequent burping. The main priority is to ensure adequate nutrition. Breastfeeding can sometimes be successful.

REF: p. 273

20. The most powerful predictor for how much children eat is how much food is put on their plate. The MyPlate sections for kids are different from those of adults.

a.
Both statements are true.
b.
Both statements are false.
c.
The first statement is true; the second is false.
d.
The first statement is false; the second is true.

ANS: C

The MyPlate sections for kids are the same as for adults, but serving sizes differ, so smaller sized plates are encouraged. Large portion sizes of snacks and fast foods parallel dramatic increases in childhood obesity.

REF: p. 283

21. Each of the following feeding tips provided by the dental hygienist are considered sound except one. Which one is the exception?

a.
Parents should assume control of food portions and not rely on the child’s internal hunger cues.
b.
Family mealtime is essential for children’s nutrition, health, and overall well-being.
c.
Children should play actively every day.
d.
Smaller plates should be used for children.
e.
Diets high in fat, sugar, and processed content may be associated with reduction in IQ.

ANS: A

Parents should allow the child to focus on internal cues of hunger; this develops the ability to regulate meal size. When parents assume control of food portions or coerce the child to eat, this development is diminished. Smaller plate size is encouraged because the MyPlate sections are the same as for adults, but serving sizes differ. The Physical Activity links on the ChooseMyPlate.com website provide information and encourage physical activities that balance energy intake for a healthy lifestyle. The Institute of Medicine recommends that toddlers and preschool children be provided with opportunities for light, moderate, and vigorous physical activity for at least 15 minutes per hour.

REF: pp. 274-277

22. Tooth eruption patterns of school-aged children are marked by exfoliation of all or most primary teeth and eruption of permanent teeth. During this period, application of topical fluoride is less effective than systemic fluoride administration.

a.
Both statements are true.
b.
Both statements are false.
c.
The first statement is true; the second is false.
d.
The first statement is false; the second is true.

ANS: C

Once teeth have erupted, application of topical fluoride, whether professionally applied or self-applied, becomes as effective as systemic fluoride administration. It is important for dental hygienists to share this fact with parents, teachers, school administrators, and anyone who might be in a decision-making capability regarding fluoride administration. At school, fluoride rinses particularly benefit school-aged children.

REF: p. 282

23. The slow childhood growth rate accelerates with pubescence until the rate is as rapid as that of early infancy. During pubescence, growth of long bones, secondary sexual maturation, and fat and muscle deposition create an increased nutrient requirement.

a.
Both statements are true.
b.
Both statements are false.
c.
The first statement is true; the second is false.
d.
The first statement is false; the second is true.

ANS: A

These statements, both correct, emphasize the critical nature of nutrition in adolescents. Major biological, social, psychological, and cognitive changes occur during this period. Because of these changes and rapid growth rates, 17% of U.S. teens are considered at nutritional risk for developing chronic diseases later in life.

REF: pp. 282-283

24. Each of the following is commonly deficient in the diet of adolescents except one. Which one is the exception?

a.
Fiber
b.
Protein
c.
Riboflavin
d.
Calcium
e.
Vitamin D

ANS: B

Average protein in adolescents is well above average. If overall intake becomes insufficient for any reason, dietary protein can be used for energy and would not be available for needed growth and repair. Note that while the need for calcium, vitamin D, and iron is of particular concern throughout childhood, the need for these nutrients is critical during adolescence because of extensive bone development.

REF: p. 282

25. The best way to prevent osteoporosis is through building bone mass during what stage of life?

a.
Infancy
b.
Early childhood
c.
Adolescence
d.
Young adulthood

ANS: C

It is thought that adolescence is the best time to build sufficient bone mass to prevent osteoporosis later in life. During this period, 45% of adult skeletal mass is formed. Calcium needs are greater at this period than at any other time. Additionally, vitamin D deficiency in adolescents can place them at greater risk.

REF: p. 283

26. Each of the following is helpful information for the dental hygienist to convey regarding iron consumption and prevention of anemia except one. Which one is the exception?

a.
Iron deficiency in exclusively breastfed infants is rare.
b.
The incidence of anemia usually declines with age.
c.
Anemia is observed more often in African American children than in white or Asian children.
d.
Consuming vitamin C with iron-rich foods diminished absorption of iron.
e.
Milk is a poor source of iron.

ANS: D

Many iron-rich foods such as meat, fresh fruits, and vegetables contain vitamin C that enhances iron absorption. Unfortunately, these foods are more expensive than calorically dense foods such as chips or candy. Note that milk is a poor source of iron, and large amounts of milk deter absorption of iron. Iron deficiency during infancy results in lower cognitive abilities and motor skills that continue throughout childhood and adolescence.

REF: p. 277

27. A mother of a toddler is concerned because her son is not eating well. Each of the following is a sound tip the dental hygienist can provide except one. Which one is the exception?

a.
Until age 6, a good rule of thumb is 1 Tbsp of vegetables, fruit, or meat per year of life.
b.
Brightly colored foods are especially appealing to children.
c.
Food jags should be discouraged with the parent taking charge of food intake.
d.
If sufficient amounts are not eaten at meals, snacks should be limited to nutrient-dense selections.
e.
If a child has been active, a short rest before a meal improves intake.

ANS: C

Food jags, refusing to eat anything except one food for several days, are common and are one way that toddlers and children assert independence. This typical developmental stage is temporary. Parents should refrain from forcing children to eat when they are not hungry. Instead, if sufficient amounts are not eaten at a meal, parents should limit snacking or provide nutrient-dense snacks. Note also that tired children eat poorly; before a meal, a short rest following activity is beneficial.

REF: p. 279

28. A mother asks about healthy snacks for her three children under 4 years old. All the following are wise choices the dental hygienist can recommend except one. Which one is the exception?

a.
Low-fat milk or yogurt
b.
Whole-grain cereals
c.
Raw vegetable sticks
d.
Cheese cubes
e.
Nuts and seeds

ANS: E

Until age 4, children are at risk for choking on food that gets caught in the airway. Food is not chewed thoroughly until the molars erupt. Small nuts and seeds are likely to cause choking. Other foods that cause choking include round, firm, smooth foods such as grapes, hard candy, hot dogs and round candies. Note that raw carrots are also in the list of foods likely to cause choking; as with all foods, parental supervision is paramount. The remaining selections, under parental supervision, are excellent nutrient-dense snack choices.

REF: p. 279

29. Children with cerebral palsy, Down syndrome, and intellectual disabilities are likely to have abnormal sensory input and muscle tone. A small, underdeveloped tongue is common in many such disorders and results in diminished nutritional status.

a.
Both statements are true.
b.
Both statements are false.
c.
The first statement is true; the second is false.
d.
The first statement is false; the second is true.

ANS: C

Common to children with special needs is tongue thrust, which jeopardizes nutritional status because of significant food waste during feeding. Difficulties with sucking, swallowing, spoon-feeding, chewing development, and independent feeding are common.

REF: p. 281

30. Sticky carbohydrate foods such as candies, cookies, and pastries are cariogenic, but crackers and raisins are not because crackers and raisins contain less processed, more natural ingredients.

ANS: E

Although crackers and raisins are more healthy foods, they are high in carbohydrates and should be limited as snacks. This, combined with their sticky nature, contributes to their cariogenic potential. Dental hygienists can help parents understand such important distinctions. Such conversations provide ideal opportunities to incorporate nutritional advice with oral hygiene recommendations.

REF: p. 284

MULTIPLE RESPONSE

1. Which of the following is true of protein requirements for infants? (Select all that apply.)

a.
Adequate intake for protein is 1.52 g/kg from birth to 6 months of age.
b.
The recommended dietary allowance for older infants is 1.78 g/kg.
c.
Recommended protein intakes are based on mean protein intake of breastfed infants.
d.
Recommended protein intakes translate to about 9.1 to 11 g per day.

ANS: A, C, D

The recommended dietary allowance for older infants is 1.2 g/kg. Note that the percentage by body weight declines as the infant develops. Breast milk and artificial breast milk (commercial formula) provide approximately 50% of kilocalories from fat to supply the high energy needs.

REF: p. 266

2. Which of the following is true of early childhood caries (ECC)? (Select all that apply.)

a.
ECC is the current most current term describing this condition.
b.
ECC is characterized by early rampant decay.
c.
ECC is associated with inappropriate feeding practice.
d.
Severe early childhood caries is the preferred terminology by pediatricians.
e.
Infants with ECC are typically overweight because of eating patterns.

ANS: A, B, C

Early childhood caries is the preferred terminology; it replaces severe early childhood caries and baby bottle tooth decay. The growth of infants with ECC can be inhibited because of pain associated with eating. Any sign of smooth surface caries in children younger than 3 years is indicative of this serious public health problem, especially prevalent in lower socioeconomic groups.

REF: p. 271

3. Early childhood caries causes destruction of tooth surfaces. Which of the following accurately describe aspects of early childhood caries (ECC)? (Select all that apply.)

a.
The primary contributing factor to ECC is infection with lactobacilli.
b.
Bacterial colonization occurs prior to tooth eruption.
c.
Infection occurs through transmission of the pathogen from caregiver to the infant.
d.
The addition of frequent or prolonged exposure to a fermentable carbohydrate is an additional factor.
e.
Damage from tooth decay can progress to rampant caries and abscesses.

ANS: C, D, E

The primary contributing factor to ECC is infection with Streptococcus mutans (cariogenic bacterium). Colonization of S. mutans occurs only after the infant’s teeth erupt. Important for parents to understand, kissing and sharing utensils or other object contaminated with saliva are contributing factors. In addition, the infant is more likely to be infected if the caregiver has a high level of S. mutans.

REF: p. 272

4. When counseling a parent regarding early childhood caries (ECC), advice from the dental hygienist should include the which of the following? (Select all that apply.)

a.
Limit the child’s access to a sippy cup containing milk or juice.
b.
If natural fluoride is low, install a home filtration system to add fluoride.
c.
During the first year, food that requires chewing should be added based on the number of erupted teeth.
d.
Wean the infant from the bottle soon after the first birthday.
e.
To encourage more consumption of fluids, add fruit juice to bottle and sippy cup.

ANS: A, C, D

Home filtration systems can remove fluoride; therefore, tests conducted by state health departments to measure fluoride content of filtered and treated water should be performed. Fruit juice adds unnecessary carbohydrates that are cariogenic. With both the sippy cup and bottle, fluids linger in the mouth enhancing the action of cariogenic bacteria. Juice should be offered in a cup.

REF: p. 272

5. Which of the following are sound recommendations regarding children’s oral health? (Select all that apply.)

a.
Water is the ideal beverage between meals.
b.
Encourage the use of fluoridate toothpaste once teeth have erupted.
c.
Recommendations for fluoride usage should be determined by need and based on risk indicators.
d.
Teach children to use a quarter-sized amount of toothpaste to limit the amount accidentally swallowed.
e.
Refer low-income patients to appropriate government agencies such as WIC or food stamp programs.

ANS: A, C, E

Fluoridated toothpastes should not be used by children less than 2 to 3 years of age. The parent should supervise and be confident that the child is not swallowing the dentifrice. The appropriate amount of toothpaste is a pea-sized portion.

REF: pp. 274-277

6. Which snack should the dental hygienist encourage to decrease incidence of dental caries? (Select all that apply.)

a.
Cheese cubes
b.
Crackers
c.
Pastries
d.
Raw vegetables

ANS: A, D

Cheese cubes decrease caries potential by neutralizing (raising pH) salivary acids. The fibrous nature of raw vegetables provides a self-cleansing mechanism and contributes to the buffering capacity of saliva.

REF: p. 279 | Dental Considerations

MATCHING

Dental hygienists working with new parents, infants, and children should be familiar with normal growth and development patterns and effectively communicate nutritional needs. Match each nutritional and oral term with its most appropriate description.

a.
DHA
b.
Necrotizing enterocolitis
c.
Omega-3 fatty acids
d.
Innate desire
e.
Attention-deficit/hyperactivity disorder
f.
Bruxism
g.
Sealants

1. Cellular dead patches in intestines

2. Caries protective physical barrier

3. Preference for sweet foods

4. Contributes to ongoing cognitive development

5. Natural ingredient in breast milk related to brain and retinal development

6. The most common developmental disorder of children

7. Involuntary grinding or clenching of teeth

1. ANS: B REF: pp. 267-284

2. ANS: G REF: pp. 267-284

3. ANS: D REF: pp. 267-284

4. ANS: C REF: pp. 267-284