WRITTEN BY
Dr. Joseph Benbassat, Pediatric Dentist

More than 40% of children have dental caries by the time they reach kindergarten, or their first dental visit. Most, if not all, of these cavities in infants and young children can easily be prevented by providing new parents with the proper information on how to look after their children’s oral health. It is therefore extremely important that early on, new parents be made aware of proper oral care of their new infants by their family doctor, Pediatrician, or most preferably, by a Pediatric Dentist.

The most commonly known dental problem affecting young children is Early Childhood Caries (ECC), which is caused by the excessive use of a baby-bottle containing apple/orange juice or formula/milk. It is also known as Nursing/Baby Bottle Caries and it can be a particularly virulent form of dental caries. It usually begins soon after dental eruption, developing on smooth dental surfaces (specifically behind the upper front teeth thus making it difficult for parents to notice it early), progressing rapidly, and having a potentially lasting and detrimental impact on the dentition.

Children experiencing caries as infants or toddlers have a much greater probability of subsequent caries in both the primary and permanent dentitions. Not only does ECC affect teeth, but consequences of this disease may lead to more widespread health issues. Infants with ECC, for example, grow at a slower pace than caries-free infants.

The presence of ECC can cause pain and suffering to young children and its treatment can often times be complicated, costly and very stressful to parents. Therefore, prevention through good parental education, is imperative.

To decrease the risk of developing ECC the following practices are suggested:

1. Minimizing saliva-sharing activities (e.g. sharing utensils) between an infant and his family, because caries causing bacteria may be transmitted to your infant by a parent or another child in the family. In addition, decreasing the mother’s/siblings’ oral bacteria levels may decrease the infant’s risk of developing ECC.

2. Implementing oral hygiene measures no later than the time of eruption of the first primary tooth.

•  If an infant falls asleep while feeding, the teeth should be cleaned before placing the child in bed.
•  Brushing the child’s teeth should be performed twice daily, especially prior to going to sleep.
•  Flossing should be initiated when teeth are not spaced apart, irrespective of the child’s age.               

3. Avoiding caries-promoting feeding behaviors. In particular:

•  Ad libitum breast-feeding should be avoided after the first primary tooth begins to erupt and other dietary carbohydrates are introduced.
•  Infants should not be put to sleep with a bottle containing anything other than water.
•  Infants should be weaned from the bottle at 12 to 14 months of age.
•  Repetitive drinking of sweet drinks from a bottle or no-spill training cup should be avoided.
•  Between meal snacks and prolonged exposure to sweets and juice should be avoided.

4. Have your child examined by a Pediatric Dentist no later than by age 2 yrs.

Dr. Joseph Benbassat, Pediatric Dentist
www.benbassatdentistry.com
Please address your questions or requests for further information to: drjbdent@gmail.com

(c) Dr. Joseph Benbassat

Q. When will my son drop his final nap?
My son is almost 3 years old and has recently stopped napping. He is very tired in the late afternoon and sometimes falls asleep on the couch. When this happens, getting him to bed before 9:30pm is very difficult! Is there anything I can do to get him napping again? 

Dr. Cohen:
Many children drop their single (afternoon) nap between 3-5 years of age. However many 3 year olds still need to nap and have trouble making it to bed time without their nap. A nap may be dropped prematurely due to social activities or because a child starts resisting the afternoon nap at the usual time. I am an advocate of not dropping a child’s nap because of social activities but parents make this decision considering a variety of factors. Sometimes if a child starts resisting their nap it is helpful to move it later by 30-60 minutes to increase his drive to sleep. A 3-5 year old, for example, may not be ready to nap before 2:00-3:00pm.

If however, a later nap is interfering with falling asleep at night, limiting the nap (e.g., to an hour) and/or moving bedtime later (e.g., to 8:30pm) may be necessary. In some cases – when a later nap interferes with even a later bedtime or the child still resists napping at a later time – these may be signs that the child is ready to go without a nap. Eliminating the nap and moving bedtime earlier may be necessary.

Some children, during the transition in dropping their nap, may still need to nap periodically as their sleep debt builds. So continue to offer your child an opportunity to nap. On some days he may and on other days he may not. Replacing the nap with ‘quiet time’ can give everyone a bit of a break from an otherwise busy day!

Q. When do children transition from 2 naps to 1?
My daughter is 13 months old and has started to resist napping twice a day. Sometimes she does and on other days she will only nap once. Can you please discuss how and when the transition from 2 naps to 1 is expected to happen?

Dr. Cohen:
Usually the 2nd nap is dropped between 12-18 months of age, with an average age being 14-16 months. However, some toddlers still need 2 naps a day until as late as 20 months of age. A sign that it may be time to drop the 2nd nap is that a child is resisting the 1st or 2nd nap at appropriate times, which is usually after 3-4 hours of being awake. When this happens for more than 3-5 days in a row, the single nap can be scheduled around the mid-day mark and gradually moved later (e.g., 1 pm at 2 years of age). However during the first few weeks of this transition, there may be some days where she still needs 2 naps and other days when 1 is enough.

When the 2nd nap is dropped, bedtime may need to be temporarily moved earlier while the child gets used to having 1 longer nap and being awake for a longer period before bed. Usually the single nap is 1.5-3 hours in length. If your child has a fragment (i.e., an early waking) during his nap and/or still seems tired, give her 15 minutes or so to see if she will fall back asleep. It is important that toddlers are falling asleep independently for their nap(s) and at nighttime, and are being responded to appropriately and consistently. If children do not have the skill of falling asleep independently they will need assistance when they have an early waking both at night and during their nap.

An early morning wake time (in children over 1 year) can be another sign that a child is ready to drop her morning nap. In these children, maintaining the morning nap can result in early morning wakings because the body does not need to sleep to a regular hour and have a morning nap. Therefore the body starts to learn that because another sleep period is coming, it can wake early. Making changes to the daytime sleep schedule (i.e., dropping the morning nap) often resolves early morning wakings that are due to this cause.

Q. How can I get my infant to have longer naps?  
My son is 6 months old and his daytime sleep is very erratic. He has 4-5 “cat-naps� a day and usually only sleeps for 30-40 minutes at each nap. He often wakes up crying and still tired and will only sleep for longer periods in his stroller. He falls asleep on his own at night, but I am still rocking him to sleep for his naps. At his age, what can I do to encourage better napping?

Dr. Cohen:
Many 6 month olds nap 2-3 times a day. Usually the third nap is dropped between 6-9 months of age. At 3-4 months of age, most healthy full-term babies are capable of falling asleep independently for all of their sleep periods (both day and night). The skill of falling asleep independently is more easily learned at sleep onset for nighttime sleep as the drive to sleep is stronger than it is for daytime sleep. Once a child has mastered the skill at nighttime, he can be given the opportunity to learn it for his naps.

“Cat naps� can be due to several reasons including: (1) being put down too early (as the drive to sleep is not as strong as it should be), (2) not falling asleep independently, and (3) being given the opportunity to nap too many times throughout the day (as the body learns it does not have to sleep very long because it will be offered another sleep period soon). Many 6 month olds are ready to sleep after 2-2.5 hours after being awake if they are having 3 naps a day, and after 2.5-3 hours if they are napping twice a day.

Usually when sleep training for naps is initiated, and even following sleep training, some children continue to have fragments (i.e., early wakings) in their naps. However, if the timing of the naps is appropriate, many children will fall back asleep, if given the opportunity. If a child has slept for less than 1 hour for a nap (i.e., less than a full cycle of sleep), sometimes giving him 15-20 minutes to see if he will fall back asleep can be helpful. 
Pleasant dreams!

Dr. Nicky Cohen is a Registered Psychologist in private practice in Toronto. She received her Ph.D. in Clinical Psychology from York University and developed an interest in parenting issues related to children’s sleep disturbances after having her first child 5 years ago. She is active in the community disseminating information on healthy sleep practices and increasing awareness of the importance of making sufficient sleep a family priority. Dr. Cohen has held various research and clinical positions at the Centre for Addiction and Mental Health, the Hospital for Sick Children, and the University Health Network (Toronto General Hospital). More information about Dr. Cohen’s work can be found at: www.kidsleep.ca.