Oral health messages for Australia: A national consensus statement

BACKGROUND

Oral health promotion initiatives must be evidence-based and consistent with broader health messaging. The Oral Health Messages for the Australian Public were first produced in 2009 and sought to enable a focused, and strategic approach to oral health promotion in Australia. As the evidence base and needs of the Australian population have since changed, this consensus statement was updated in 2022-2023.

METHODS

The process of updating the messages consisted of 3 phases (preparatory phase, the Delphi technique, final revision phase). The preparatory phase included public and expert consultation, an umbrella review of published scientific literature and review of available recommendations, policies and guidelines. The Delphi technique used in this study was guided by Guidance on Conducting and REporting DElphi Studies (CREDES) and included 2 voting rounds. There were 70 experts in round 1 and 60 experts in round 2. Delphi participants comprised of experts from a variety of fields to ensure diversity and inclusion, balance expertise and maximize stakeholder representation. Consensus was defined as 75% agreement.

RESULTS

A total of 11 messages were included in the 2022 update of Oral Health Messages for Australia.

CONCLUSION

The updated oral health messages will support oral health promotion policy and activity at both individual and population level to improve the oral health of Australians.

Does Dental Caries Increase Risk of Undernutrition in Children?

INTRODUCTION

A systematic review of the evidence on the impact of dental caries on malnutrition risk in children was conducted.

OBJECTIVES

To systematically review published evidence pertaining to the effect of dental caries severity and prevalence on risk of wasting or stunting in children.

METHODS

Four questions relating to caries of the permanent dentition, primary dentition, early childhood caries (ECC), and severe ECC as a risk factor for undernutrition were set. The target population was children aged 0 to 18 y from any country. Data sources included MEDLINE and Embase. All human epidemiological studies were included. Quality assessment excluded lowest-quality studies. Evidence synthesis by vote counting was depicted using harvest plots. A best available evidence approach was applied to narrative synthesis. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

RESULTS

Of the 2,690 studies identified, 447 were screened in duplicate; of these, 117 underwent quality assessment, resulting in 46 included studies, of which 38 were included in vote counting (3 quasi-experimental, 1 cohort, 1 case control, and 33 cross-sectional studies). For the permanent dentition, findings were mixed; the balance of data showed no association between caries prevalence (7/11 studies) or severity (8/17 studies) with wasting. For the primary dentition, the balance of data showed a positive association between caries prevalence (10/15 studies) and severity (12/15 studies) with wasting, as well as between-caries prevalence (4/5 studies) and severity (6/6 studies) with stunting. Considering ECC only did not alter this pattern of findings.

CONCLUSION

The balance of evidence suggests that dental caries in the primary dentition is associated with undernutrition. There is a need for well-designed trials on the impact of caries rehabilitation on growth trajectories of children from low- and middle-income countries and for prospective studies of the impact of caries severity on both stunting and wasting to confirm causality.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by policy makers when considering the importance of oral health in addressing the United Nations Sustainable Development Goal to end all forms of malnutrition. The findings suggest that dental caries in the primary dentition may impair children's healthy weight gain. The findings indicate that higher-quality data are required to confirm a causal relationship and thus inform funding bodies of the need for research, especially in low- and middle-income countries, to substantiate the current knowledge and inform clear and accurate policy statements.

Impact of Wearing Dentures on Dietary Intake, Nutritional Status, and Eating: A Systematic Review

INTRODUCTION

A key purpose of denture provision is to enable eating, yet the body of evidence pertaining to the impact of dentures on wide-ranging nutritional outcomes has not been systematically reviewed.

OBJECTIVES

To systematically review published evidence pertaining to the effect of wearing removable dental prosthesis on dietary intake, nutritional status, eating function, and eating related-quality of life (ERQoL).

METHODS

Eight questions relating to the impact of wearing dentures on nutritional outcomes were addressed. The target population was healthy adults aged ≥18 y. Data sources included Medline, Embase, CINAHL, and PubMed. Included were all human epidemiologic studies. The Newcastle-Ottawa score was used for appraisal of study quality. Harvest plots, vote counting, and accompanying narrative provided the basis for synthesis.

RESULTS

Of the 1,245 records identified, 134 were retrieved and eligibility assessed by 2 reviewers, and 41 studies were included in the synthesis (14 rated good quality, 20 fair, and 7 poor). The balance of data supported a positive impact of wearing full (5/7 studies) or partial (3/3 studies) dentures (vs. no dentures) on nutritional status, though no clear direction of effect was detected for the impact of dentures on dietary intake. The balance of data clearly showed that objective measures of eating function were compromised in full (14/15 studies) and partial (6/7 studies) denture wearers as compared with the dentate. Data showed that ERQoL was also compromised in denture wearers as compared with the dentate (3/3 studies). However, data showed a positive impact of wearing dentures on ERQoL (5/5 studies) as opposed to wearing no dentures.

CONCLUSION

The balance of evidence shows that despite no clear pattern on impact of wearing dentures on measured dietary intake, in those with tooth loss, wearing dentures can have a positive impact on nutritional status and enjoyment of eating.

KNOWLEDGE TRANSFER STATEMENT

The results of this systematic review can be used to advocate for health care services to address prosthodontic need to benefit nutritional outcomes. The findings will be of use in educating health care professionals on the impact of wearing dentures and not addressing prosthodontic need on nutritional outcomes.

Excess Risk of Dental Caries from Higher Free Sugars Intake Combined with Low Exposure to Water Fluoridation

The study aimed to quantify the excess risk of interaction between high free sugars (sugars) intake and lack of exposure to water fluoridation on child dental caries. Data from the Australian National Child Oral Health Study, a population-based survey of 24,664 children aged 5 to 14 y, were collected using parental questionnaires and oral epidemiological examinations by trained examiners. Information on socioeconomic status, dental health behaviors, and dental service use was used as covariates. The number of servings of sugars-containing foods and drinks consumed in a usual day was assessed as the main exposure, categorized into 5 groups. Residential history was used to calculate lifetime exposure to fluoridated water (LEFW), categorized as low (<25%), medium (25% to <75%), or high (75%-100%). Caries prevalence (dmfs/DMFS >0) and experience (dmfs/DMFS) in the primary (ages 5-10 y) and permanent (ages 8-14 y) dentitions were the main dependent variables. The association of sugars intake and LEFW with each outcome was estimated in multivariable log-Poisson regression models with robust standard error estimation, adjusted for covariates. The relative excess risk due to interaction (RERI) between sugars intake and LEFW was estimated. Strong positive gradients in all outcomes were observed across sugars intake groups. Relative to the lowest intake group, the 3 highest intake groups had significantly higher adjusted prevalence ratios for having caries and higher adjusted mean ratios of caries experience in both dentitions, after controlling for all covariates. LEFW strongly and consistently attenuated the effects of all levels of sugars intake on the outcomes. RERI estimates indicated that a combination of lack of exposure to fluoridated water and high sugars intake resulted in greater excess risk of primary and permanent caries than if there was no interaction. Evidently, children with high sugars intakes and low exposure to water fluoridation are at disproportionately higher risk of dental caries.

Oral Health Impacts on Flavor and Significance in Dental Treatment

The mouth is pivotal in the generation of flavor, the pleasure of eating, and the selection of food. Flavor-representing the integration of olfaction (smell) with gustation (physiologic taste) and as influenced by oral somatosenses-is rarely afforded attention in oral research and dental practice. This article considers the interrelationship between oral health and flavor and highlights gaps in current knowledge. Altered oral function associated with operative and restorative treatment can feasibly alter the perception of flavor through diverse ways. Oral diseases and the generation of biofilms on restorative materials have potential to influence the oral microbiota and the perception of flavor. Alterations in masticatory function (through tooth loss, restorative materials, and prostheses with nonbiological surfaces and shapes) compounded by associated influences in the composition and quantity of saliva can affect the release of odorants and tastants from foods and beverages. Furthermore, changes occur in the perception of flavor throughout life and are significant in the aging and medically compromised population with the potential to affect nutrition and pleasure. Dental research and clinical practice should be at the forefront of biomedical science in understanding and promoting the importance and relevance of flavor in the well-being of patients. However, more research is required to guide clinical practice in consideration of olfactory and gustatory function as a component of total patient care.Knowledge Transfer Statement: This commentary highlights the research gaps in knowledge pertaining to the association between oral health and flavor and the significance of flavor to dental practice.

Beyond the Chair: Public Health and Governmental Measures to Tackle Sugar

Limiting free sugars to <5% of energy intake is a World Health Organization evidence-based recommendation to protect oral health throughout the life course. Achieving this requires a concerted approach with upstream interventions, including legislation underpinning community interventions and health promotion. Global production and trade are the main drivers of sugars consumption, which can be addressed only through prioritization of health impacts in agricultural and trade agreements, including pricing and subsidies. Increasing evidence demonstrates the benefit, including dental benefits, of taxes on sugar-sweetened beverages, a major source of sugars—with taxes based on sugars content being favored due to the dual impact in incentivizing consumers to buy less and encouraging producers to use less through product reformulation. A benefit of product reformulation is that the potential impact on sugars intake occurs independent of consumer behavior change, making the benefits more equitable across social groups. Evidence from meta-analysis indicates that sugars reformulation and portion size reduction could lower energy intake by more than 10% and 16%, respectively. Sophisticated and targeted digital marketing of products high in sugars is another key driver of sugars intake. With the exception of children’s television broadcasting, marketing of products high in sugars is largely unregulated, and increased awareness of modern marketing strategies and more stringent regulation are urgently needed. To ensure a commercial level playing field, mandatory approaches are required. Midstream actions include creating healthier food environments in neighborhoods, community settings (schools, sports centers, hospitals), and workplaces. Only through coalition among authorities responsible for planning and health will “obesogenic and cariogenic” environments be replaced with those that make healthy choices the easiest choice. It is recognized that providing nutrition health education alone is insufficient to achieve necessary sugars reduction; however, education has a key role to play in changing social norms and creating drive for change.

Systematic Review of Evidence Pertaining to Factors That Modify Risk of Early Childhood Caries

INTRODUCTION

A systematic review of evidence on the impact of modifiable risk factors on early childhood caries (ECC) was conducted to inform recommendations in a World Health Organization manual on ECC prevention.

OBJECTIVES

To systematically review published evidence pertaining to the effect of modifiable risk factors on ECC.

METHODS

Twelve questions relating to infant feeding, diet, oral hygiene, and fluoride were addressed, as prioritized by a World Health Organization expert panel. Questions pertaining to the use of fluoride toothpaste were excluded due to its proven efficacy. The target population was children aged <72 mo. Data sources included Medline, Embase, CINAHL, and PubMed, and all human epidemiologic studies were included. The highest level of evidence was used for evidence synthesis and, where possible, meta-analysis. The review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement, with evidence assessed via the GRADE method.

RESULTS

Of the 13,831 papers identified, 627 were screened in duplicate; of these, 139 were included. The highest-level evidence indicated that breastfeeding ≤24 mo does not increase ECC risk but suggested that longer-duration breastfeeding increases risk (low-quality evidence). Low-quality evidence indicated increased risk associated with consumption of sugars in bottles. Only 1 study had data on the impact of sugars in complementary foods, which increased risk. Moderate-quality evidence showed a benefit of oral health education for caregivers (odds ratio, 0.39; 95% CI, 0.19 to 0.80, P = 0.009). Meta-analysis of data on the impact on ECC from living in a fluoridated area showed a significant effect (mean difference, -1.25; 95% CI, -1.24 to -0.36; P = 0.006). Limited moderate- and low-quality data indicated a benefit of fluoride exposure from salt and milk, respectively.

CONCLUSION

The best available evidence indicates that breastfeeding up to 2 y of age does not increase ECC risk. Providing access to fluoridated water and educating caregivers are justified approaches to ECC prevention. Limiting sugars in bottles and complementary foods should be part of this education.

KNOWLEDGE TRANSFER STATEMENT

This research is being used by the World Health Organization in developing a toolkit on the prevention and management of early childhood caries. The information will guide 1) governments in developing national oral health plans and 2) clinicians when providing preventive advice, including that regarding infant feeding practices. It will help ensure that advice is in line with current World Health Organization guidelines and the best available evidence.

Free Sugars Consumption around Bedtime and Dental Caries in Children: A Systematic Review

This systematic review aimed to assess the association between food and drink consumption around bedtime-specifically, food and drinks containing free sugars-and the risk of dental caries in children. Five electronic databases were searched (PubMed, Ovid Medline, EMBASE, Web of Science, and Scopus) to identify studies that investigated any relationship between food and drink around bedtime and dental caries in 3- to 16-y-old children. The Agency for Healthcare Research and Quality domain guidelines were used to assess the quality of the individual studies, while GRADE guidelines assessed the quality of studies based on the body of evidence. From 1,270 retrieved titles, 777 remained after removal of duplicates. Of these, 72 were reviewed in full. Eighteen studies fulfilled the inclusion criteria and were included in the analysis: 13 cross-sectional, 4 cohort, and 1 case-control. Studies were categorized into 3 age groups: 3- to 5-y-old, 6- to 11-y-old, and 12- to 16-y-old children. Based on the Agency for Healthcare Research and Quality criteria, 6 of the 18 studies were rated as providing good-quality evidence; 8 were rated as fair; and 4 were categorized as being of poor quality. It was not possible to conduct a meta-analysis, because of the considerable variations in the type of bedtime exposure and outcome measures. The studies showed a consistent positive association across the 3 age groups, with all 7 studies on preschool children reporting significant positive associations. However, the quality of the body of evidence pertaining to the consumption of food and drinks at bedtime (specifically, food and drinks containing free sugars) and risk of caries was rated as "very low." The results suggest that restricting free sugars before and at bedtime may reduce the risk of caries, but studies with improved design are needed to confirm this. Knowledge Transfer Statement: This is the first systematic review of the evidence assessing the association between caries risk in children and the consumption of food or drinks at bedtime-specifically, foods and drinks containing free sugars. Although the data showed a consistent positive association, the quality of evidence was very low. This means that the current recommendation to restrict food and drinks containing free sugars before bedtime in children, while based on a sound physiologic premise, is supported only by very low-quality published evidence as measured by GRADE guidelines.

Breastfeeding and Oral Health: Evidence and Methodological Challenges

Breastfeeding is a powerful health-promoting behavior. A 2016 Lancet global collaboration to review the health implications of breastfeeding was among the first to consider oral health outcomes. While a role was suggested for breastfeeding in preventing malocclusion, caries was the only included disease condition unfavorably associated with breastfeeding. The present critical review examines the evidence connecting breastfeeding practices to these outcomes and discusses the methodological challenges inherent in reaching causal conclusions. Published systematic reviews show some evidence of a protective effect of breastfeeding against primary dentition malocclusion but no supportive evidence for mixed dentition and permanent dentition malocclusions. Regarding caries, well-conducted studies report a benefit with breastfeeding up to 12 mo but a positive association between caries and breastfeeding of longer duration, at times that vary between 12 and 24 mo, as well as nocturnal feeding. Future studies would be methodologically stronger if focused on specific malocclusion traits that are plausibly associated with sucking movements rather than using general malocclusion indices. Studies should use detailed and consistent terminology for breastfeeding definition, including frequency, intensity, and timing. Analytical studies should be carried out to distinguish between confounders (e.g., prematurity) and mediators (e.g., use of pacifier). Regarding a link to caries, standard terminology for exposures (e.g., nocturnal feeding) is recommended. Statistical analyses must account for known confounding factors (e.g., socioeconomic conditions) but avoid inappropriate adjustment for variables on a causal path between exposure and outcome or for variables not associated with breastfeeding (e.g., tooth brushing), as can be guided using tools such as direct acyclic graphs. For dental practice, the potential caries risk of long-duration breastfeeding should be part of individual patient counseling that incorporates patient values and circumstances. Given the unquestioned overall health benefits of breastfeeding, the dental community should support World Health Organization guidelines that encourage and promote breastfeeding.

Fractional Urinary Fluoride Excretion (FUFE) of 3-4 year children in the Gaza Strip

A positive association between dental fluorosis prevalence and fluoride (F) concentration in drinking waters has been detected in Gaza Strip. Total Daily Fluoride Retention (TDFR), and Fractional Urinary Fluoride Excretion (FUFE) indicate F body burden; important in assessing fluorosis risk in susceptible age groups.

OBJECTIVE

1, To determine and compare Daily Urinary Fluoride Excretion (DUFE) and FUFE of 3-4-year-olds living in lower (< 0.7), moderate (0.7-1.2) or higher (> 1.2 ) ppm F tap water areas; 2, To determine any relationship between i, DUFE and tap water F; ii, DUFE and Total Daily Fluoride Intake (TDFI); iii, TDFI and TDFR.

METHODS

24-hour urine and tap water samples were collected from 216 children exposed to lower (n = 81), moderate (n = 72), or higher (n = 63) tap water F. ANOVA with Tukey's Test and Pearson's correlation were used to examine differences in mean DUFE and FUFE and relationships between variables.

RESULTS

Mean drinking water F was 0.11(sd 0.17), 0.14 (sd 0.28) and 0.38 (sd 0.63) ppmF respectively. Differences (p < 0.0001) in mean DUFEs (0.17 (sd 0.13), 0.25 (sd 0.15) and 0.38 (sd 0.23) mg/day respectively) and mean FUFEs (48 (sd 39)%, 47 (sd 31)% and 63(sd 76)%) were found (p < 0.05). Significant (p < 0.0001) positive correlations were found between DUFE and tap water F; DUFE and TDFI, and; TDFI and TDFR.

CONCLUSION

DUFEs of children drinking waters with 0.11 and 0.14ppm F, represented low F usage. The group drinking 0.38ppm F water represented optimal F usage. The weak significant positive association of DUFE with home tap water F suggests low validity for tap water F in estimating F exposure.

Urinary fluoride excretion in 6- to 7-year-olds ingesting milk containing 0.5 or 0.9 mg fluoride

Effectiveness of 0.5 mg fluoride (F) milk ingestion in preventing caries has been termed only 'moderate'. In this 3-arm partial cross-over intervention, 32 children aged 6-7 years in a non-F area were recruited and urinary F excretion (UFE) measured before and after ingestion of 0.5 or 0.9 mg F milk. Maintaining customary dietary and oral hygiene habits, children underwent a 2-week 'wash-in' with non-F milk, providing a 24-hour urine sample on day 4 of non-F (baseline) and F milk ingestion containing either (i) 0.5 mg or (ii) 0.9 mg F (intervention). A comparative group of thirteen 6- to 7-year-olds living in fluoridated areas provided a 24-hour urine sample on day 4 of daily non-F milk ingestion, following a 2-week non-F milk wash-in. Valid urine samples were analysed for F and UFE estimated from corrected 24-hour urine volume and F concentration. For the 24 test children providing 2 valid urine samples, mean (95% CI) change in corrected 24-hour UFE was 0.130 (0.049, 0.211) and 0.153 (0.062, 0.245) mg/day for 0.5 mg (p < 0.007) and 0.9 mg F (p < 0.001) groups, respectively. Post-intervention, mean (SD) corrected 24-hour UFE was 0.437 (0.153) mg/day and 0.420 (0.188) mg/day for the 0.5 and 0.9 mg F groups, respectively, which were lower than the WHO provisional standards (0.48-0.60 mg F/day). F milk consumption significantly increased UFE; however, the F content of 0.5 and 0.9 mg F milk may be too low to achieve WHO provisional UFE standards concomitant with optimal F exposure in children aged ≥6 years.

A questionnaire assessment of nutrition knowledge--validity and reliability issues

OBJECTIVE

This study describes an evaluation of validity and reliability measures in a questionnaire designed to assess knowledge of applied nutrition in children participating in an after-school care dietary intervention programme being undertaken in an area of high social disadvantage.

DESIGN

Three domains were assessed: Knowledge of Applied Nutrition (KN), Knowledge of Food Preparation (KP) and Perceived Confidence in Cooking Skills (PC). Four pilot studies were undertaken to determine item reliability, test-retest reliability, discrimination and difficulty indices, and content, cognitive and face validity.

SETTING

Primary schools in Dundee, Scotland and Newcastle upon Tyne, England.

SUBJECTS

Ninety-eight children aged 11 years.

RESULTS

The final instrument comprised 36 questions (18 KN items, 9 KP items and 9 PC items) presented on four sides of paper, which could be self-completed in less than 15 minutes. Question formatting included open and closed structures (KP) and multiple choice (KN and PC) items. All knowledge questions could be answered correctly by 5 to 95% of the target population, with discrimination scores ranging from 0.06 to 0.83. Retest reliability scores were significant (KN 0.458, KP 0.577, PC 0.381, ) and internal reliability (Cronbach's alpha) of each component was also significant.

CONCLUSION

The test meets basic psychometric criteria for reliability and validity and forms a suitable instrument for measuring changes associated with intervention work aimed at improving food and dietary knowledge.

The British Nutrition Foundation Oral Task Force report--issues relevant to dental health professionals

A recent report on diet and oral health by the British Nutrition Foundation reviews the anatomy, microbiology and pathology of a number of oral diseases including dental caries, tooth-wear, oral cancer, periodontal disease and enamel defects. The role of nutritional factors in the aetiology and prevention of these oral diseases is discussed. The report states that improvements in the levels of caries in the UK are halting and remain unacceptably high in some 'at risk groups'--including the socially deprived. It states that a two-pronged attack, i.e. reduced frequency of consumption of sugary foods and use of fluoride is necessary to address the problem. To address the increased prevalence of oral cancer avoiding tobacco, limiting alcohol and increasing fruit and vegetable consumption are recommended. Recommendations for approaches to improve oral health are made for health authorities, industry, schools and health professionals and it is recommended that the Government make adequate resources available to improve oral health preventive strategies.

The day the lights went out: one charge nurse's nightmare

The synergy model can be applied to many clinical situations. As nursing leaders evolve, competencies required to effectively respond to unexpected events silently develop. Applying the Synergy Model to this exemplar helped to articulate the charge nursing's leadership in ensuring a safe practice environment. The model provides a framework to more fully describe the multiple dimensions of a charge nurse's role, and acknowledges the richness of knowledge and competence that charge nurses often contribute to complex clinical situations.

The day the lights went out: one charge nurse's nightmare

The synergy model can be applied to many clinical situations. As nursing leaders evolve, competencies required to effectively respond to unexpected events silently develop. Applying the Synergy Model to this exemplar helped to articulate the charge nursing's leadership in ensuring a safe practice environment. The model provides a framework to more fully describe the multiple dimensions of a charge nurse's role, and acknowledges the richness of knowledge and competence that charge nurses often contribute to complex clinical situations.

Dietary sources of calcium and the contribution of flour fortification to total calcium intake in the diets of Northumbrian adolescents

Increased Ca intake by adolescents is desirable. In order to achieve this, information on the current dietary sources of Ca by this age group is essential to enable change to build on existing habits. This paper addresses two issues: first, the dietary sources of Ca for adolescents are reported and, second, the importance of fortification of flour with Ca to present-day Ca intakes was determined. In 1990 the diets of 379 children aged 12 years were assessed using the 3 d dietary diary and interview method. Computerized food tables were used to calculate the contributions of different food groups to total Ca intake. The Ca content of each food was subdivided into naturally occurring Ca and Ca from fortification, and data were analysed to give the daily intake of each. The four most important sources of Ca were milk (25%), beverages (12%), puddings (10%) and bread (9%). Fortification of flour accounted for 13% of total Ca intake. When the contribution of fortification was removed, the proportion of subjects with intakes of Ca below the lower reference nutrient intake (Department of Health, 1991) increased more than fourfold, to 10% of girls and 12% of boys. Milk is contributing less to Ca intake than in the past and increased consumption should be encouraged. Ca fortification of flour remains an important source of Ca. Therefore, unless dietary habits are modified to ensure adequate Ca from other sources, increased consumption of unfortified products from outside the UK will lead to a further reduction in Ca intake.

Making a transition from quality assurance to quality improvement

Health care leaders now recognize the importance of adding continuous quality improvement activities and the measurement of clinical outcomes to their longstanding quality programs. From other industry leaders, they have learned that there is great promise on quality/cost returns when quality programs focus on measuring performance outcomes rather than just using the longstanding process of measuring variation in staff and system capacity processes. The purpose of this article is to describe how one urban acute care hospital is taking steps to change its quality paradigm and therefore change its quality program, which until recently consisted largely of unrelated quality assurance activities and projects. The new system will be a truly coordinated hospital wide continuous quality improvement program that will align quality activities with the mission of the organization and focus on the measurement of outcomes.

Parent participation

Ultimate care of the critically ill child is contingent on a parent-professional partnership that acknowledges both the needs and the strengths of families. In providing pediatric care, parent participation maintains and empowers parents to care for their child. Models of care must include programs that support reempowerment rather than dependence of families. The challenge of including parents as partners in care is one of the most rewarding privileges and responsibilities of pediatric nurses.

Special nutritional needs of surgical patients

Hospital-induced malnutrition has long been recognised as a problem, particularly as the very group of people who find themselves in a hospital for treatment, whether for long- or relatively short-term treatment are, almost by definition, at risk. This paper seeks to identify the causes of treatment induced malnutrition and discusses methods that can be successfully used to overcome this avoidable condition.

The tRNAAGYSer and tRNACGYArg genes from a gene cluster in yeast mitochondrial DNA

Yeast mitochondrial DNA-pBR322 recombinant DNA molecules screened for rRNA genes were used as a source of DNA for mitochondrial tRNA gene sequence analysis. We report here the sequences of yeast mitochondrial tRNA genes coding for a tRNAAGYSer and a tRNACGYArg. The tRNAAGYSer sequence deduced from the gene is the first reported sequence of a yeast tRNAAGYSer. It is also the second yeast mitochondrial tRNASer gene to be sequenced, and demonstrates unequivocally the presence of mitochondrial encoded serine tRNA isoacceptors. The tRNACGYArg sequence deduced from the gene is the most AT-rich (82%) tRNA sequence ever reported. Whereas all the mitochondrial genes sequenced to date exist singly on the genome and are separated by long stretches of AT-rich DNA, the tRNAACYSer and tRNAcgyarg genes exist in tandem, separated by only 3 bp. This gene arrangement strongly suggests that mitochondrial tRNA genes may be transcribed into multicistronic precursors.