WATER FLUORIDATION AND INFANT FORMULA - A BRITISH FLUORIDATION SOCIETY BRIEFING PAPER

1. Background

1.1. The British Fluoridation Society considers fluoridated water to be safe for all – including babies.

1.2. The American Dental Association (ADA) endorses community water fluoridation as a safe, beneficial and cost-effective public health measure for preventing dental decay.

1.3. On November 9, 2006, the ADA issued interim guidance on fluoride intake for infants and young children. It was issued to give parents, caregivers and health care professionals, who may be concerned about dental fluorosis, some simple and effective advice on ways to reduce fluoride intake from reconstituted infant formula.

1.4. Some health professionals and parents might be alarmed by the misrepresentation of the ADA guidance by campaigners against water fluoridation.

1.5. The BFS does not believe that there is an unacceptable risk of unsightly dental fluorosis at drinking-water fluoride concentrations below the current EU (and UK) maximum admissible concentration of 1.5 mg/l in tap water. We have therefore developed this briefing to provide health professionals, and the public in the UK with the background to the issue, and to offer advice to parents who want to reduce their infants’ risk of dental fluorosis still further.

1.6. The ADA’s initiative followed the publication of a review by the US National Academy of Sciences (Committee on Fluoride in Drinking Water, 2006) which cited studies that “raised the possibility that infants could receive a greater than optimal amount of fluoride from reconstituted baby formula” – in particular an earlier publication by Foman et al (2000).

2. Foman et al 2000 review paper

Foman et al (2000) concluded in their extensive review that “considerable evidence is now available that fluoride consumption during infancy may be an overriding factor in the development of dental fluorosis in the permanent teeth”. The authors recommended that parents should:

· when feasible, use water low in fluoride for the reconstitution of infant formulae;

· supervise tooth brushing by children younger than age 5 years; and,

· should not give infants fluoride supplements (tablets of drops).

Importantly, the authors also commented that the consumption of fluoridated water by children aged 1 – 7 years is highly recommended.

3. Food Safety Authority of Ireland

WA Anderson of the Food Safety Authority of Ireland together with his colleagues prepared a detailed probabilistic estimation of fluoride intake by infants up to 4 months old living in fluoridated parts of Ireland. Their study, which was originally conducted for the Irish Government’s Forum on Fluoridation, has since been published (Anderson et al, 2004). They concluded that “these predicated intakes were well below the intake of fluoride associated with acute toxic effects…… that dental fluorosis may be considered the only risk at these low doses…. and that there is a very low risk of moderate dental fluorosis of the permanent dentition in infants exposed to fluoride at these levels”

Subsequently Dr Helen Whelton and her colleagues at University College Cork have conducted a study to identify the daily fluoride intake from formula of 80 infants consuming infant formula reconstituted with fluoridated water. Their results were similar to the results of the risk assessment undertaken by Anderson et al.

4. Further US publications

Since the National Academy of Sciences review referred to above (Committee on Fluoride in Drinking Water, 2006)) a further important and relevant publication from the Iowa Longitudinal Fluoride Study has appeared (Hong et al, 2006). This study followed a cohort of children from birth to 10 years of age and involved detailed estimates (4 per year) from birth to 4 years of age of ingested fluoride followed by a clinical assessment of dental fluorosis in permanent incisors at 8-10 years of age. The study concluded that the first two years of life were most important to dental fluorosis development in permanent maxillary central incisors (although other individual years were also important). An earlier study from the same group (Levy et al, 2001) suggested that in the first year of life water (mainly added to infant formula) was the main source of ingested fluoride, and that, during the second year, water and ingested dentifrice were both significant sources of fluoride. These studies provided some of the scientific background to the ADA’s interim guidance.

5. Relevance to the UK

A degree of dental fluorosis within the population has always been accepted as a consequence of water fluoridation – in the belief that the expected level of fluorosis was unlikely to be of cosmetic concern. However it must be recognised that what is cosmetically acceptable will vary from place to place and from generation to generation. It is not implausible as dental health and dental awareness both improve, that levels of dental fluorosis that were accepted as minor blemishes by our parents’ generation, might be of cosmetic concern to our children’s generation.

It seems a reasonable therefore to pursue the objective of continuing to receive the real and full benefits of water fluoridation while at the same time reducing even further the risks of dental fluorosis. The research briefly reviewed above suggests how this objective might be achieved. There are two relevant questions:

a) To what extent is dental fluorosis a problem (or potential problem) in fluoridated communities in the UK?

b) Is it practicable for parents to provide a low fluoride infant formula for their young children?

6. Fluorosis in the UK

In a recent briefing the British Fluoridation Society suggested that the prevalence of unsightly dental fluorosis in the UK is around 4% in fluoridated districts and less than 1% in non fluoridated districts (British Fluoridation Society, 2005). Recent studies are summarised in the table below.

The prevalence of dental fluorosis of aesthetic concern in recent UK (and Irish*) studies

Authors and year of publication	Age ** Group (years)	Year of fieldwork	Area(s) in which study was conducted	F or NF	% prevalence
Tabari et al (2000)	8 – 9	1998	Newcastle Northumberland	F NF	3% 1%
* Cochran et al (2004)	8	1997 – 1998	Cork Knowsley	F NF	4% 1%
Tavener et al (2004)	8 – 9	2001 - 2002	North-West England	NF	1%
* Whelton et al (2003)	8	2001 - 2002	Republic of Ireland Republic of Ireland Northern Ireland	F NF NF	4% 0% 0%
Chadwick and Pendry (2004)	12	2003	United Kingdom	*** NF	1%

* Irish data presented for cross-border studies.

** Youngest age group selected for studies covering more than one age group.

*** F and NF communities combined. Approx 10% of UK water supply fluoridated.

The difference in prevalence of unsightly dental fluorosis in bottle-fed as against breast-fed children in fluoridated districts in the UK is not known and should be researched. Until such data are available for the UK it would probably not be justified to run a public awareness campaign in fluoridated districts. However the ADA approach - i.e. advice from dentists/hygienists to concerned parents - might be worth considering.

7. What might a dentist say to concerned parents living in a fluoridated area

If parents resident in a fluoridated district express concern or ask their dentist or hygienist for advice about reducing their infants’ risk of dental fluorosis, we suggest the following:

· that breast feeding is the best option;

· that a ready-to-use infant formula (e.g. SMA Gold ready-to-use) has a low fluoride content (less than 100 micrograms/litre);

· that powdered formula could be made up with a suitable bottled water (see Annex)

· that toothbrushing with a smear of fluoride toothpaste (1000 ppm) should be started under parental supervision from the age of one year (note in the USA and the Republic of Ireland fluoride toothpaste is introduced from two years);

· that fluoride tablets/drops should not be used.

References

American Dental Association (2006): Interim Guidance on Reconstituted Infant Formula 9 November 2006.

Anderson WA, Pratt I, Ryan MR, Flynn A (2004): A probabilistic estimation of fluoride intake by infants up to the age of 4 months from infant formula re-constituted with tap water in the fluoridated regions of Ireland. Caries Research, 38, 421-429.

British Fluoridation Society (2005): Water Fluoridation: A briefing on the York University Systematic Review and Subsequent Research Developments. Manchester. British Fluoridation Society. http://www.bfsweb.org/York%20and%20Subsequent%20Research.pdf

Chadwick B, Pendry L (2004): Children's dental health in the United Kingdom 2003. Non-carious dental conditions. London, Office for National Statistics.

Cochran AJ, Ketley CE, Arnadottir IB, Barros F, Koletsi-Kounari H, Oila A, et al. (2004): A comparison of the prevalence of fluorosis in 8-year-old children from seven European study sites using a standardized methodology. Community Dentistry and Oral Epidemiology 32 (Supp 1): 28-33.

Committee on Fluoride in Drinking Water National Research Council (2006): Fluoride in Drinking Water: A Scientific Review of EPA's Standards. National Academy Press. Washington DC. http://darwin.nap.edu/books/030910128X/html/

Foman SJ, Ekstrand J, Zeigler EE (2000): Fluoride intake and prevalence of dental fluorosis: trends in fluoride intake with special attention to infants. Journal of Public Health Dentistry 60 131-139.

Hong L, Levy SM, Broffitt B, Warren JJ, Kanellis MJ, Wefel JS, Dawson DV (2006): Timing of fluoride intake in relation to development of fluorosis on maxillary central incisors. Community Dentistry and Oral Epidemiology 34 299-309.

http://www.ada.org/prof/resources/pubs/epubs/egram/egram_061109.pdf

Levy SM, Warren JJ, Davis CS, Kirchner HL, Kanellis MJ, Wefel JS (2001): Patterns of fluoride intake from birth to 36 months. Journal of Public Health Dentistry 61 70-77.

Tabari ED, Ellwood R, Rugg-Gunn AJ, Evans DJ, Davies RM (2000): Dental fluorosis in permanent incisor teeth in relation to water fluoridation social deprivation and toothpaste use in infancy. British Dental Journal 189: 216-220.

Tavener JA, Davies GM, Davies RM, Ellwood RP (2004): The prevalence and severity of fluorosis and other developmental defects of enamel in children who received free fluoride toothpaste containing either 440 or 1450 ppm F from the age of 12 months. Community Dental Health 21: 217-223.

Whelton H, Crowley E, O'Mullane D, Cronin M, Kelleher V (2003): Children's oral health in Ireland 2002: preliminary results. A North-South survey coordinated by the Oral Health Services Research Centre, University College Cork. Dublin, Department of Health and Children. Dublin http://www.dohc.ie/publications/pdf/coral.pdf?direct=1.

ANNEX INFANT FORMULA

1. Infant formula is available in 3 forms:

1.1. powder to be reconstituted with boiled cooled water (tap water, or appropriate bottled water, see below);

1.2. condensed liquid formula (not common in the UK) which is made up with an equal volume (50:50) of boiled cooled water (tap water, or appropriate bottled water, see below);

1.3. ready-to-use formula in 250ml or 1 litre Tetra-pak cartons which are simply decanted into a feeding bottle.

2. Prices for the powdered variety (1.1 above) are about £1.14 per litre (local Tesco price July 2008).

3. Prices for the ready-to-use variety (1.3 above) are around £1.92 per litre (local Tesco price July 2008).

4. Our suggested alternative to the ready-to-use formula (section 7 above) is to make up the powdered formula with low fluoride bottled water (i.e. fluoride less than 0.3 mg/litre).

5. Not all bottled waters are suitable for infants. However there are several suitable bottled waters available; for example Tesco’s Ashbeck Still Natural Mineral Water retails at around 19p per litre (July 2008 price). The mineral analysis is as follows:

Tesco Ashbeck Mountain Spring Still Mineral Water

Typical mineral analysis in mg/litre:

Calcium	10.0	Magnesium	2.2
Sodium	10.0	Potassium	2.3
Bicarbonate	13	Chloride	15.0
Sulphate	11.0	Nitrate	20.0
Nitrite	Less than 0.2	Fluoride	Less than 0.1

MA Lennon

British Fluoridation Society

Originally published15-Feb-07

Revised July 2008