WATER
FLUORIDATION AND INFANT FORMULA - A BRITISH FLUORIDATION SOCIETY BRIEFING PAPER*
1. Background
1.1.
The American Dental Association
(ADA) has recently issued interim guidance (attached as Annex A) to concerned
parents, caregivers and healthcare professionals of infants who consume infant
formula. The purpose of the guidance is
to reduce even further the risk of dental fluorosis.
1.2. The
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
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”
Currently Dr Helen Whelton and her colleagues at University College Cork
are measuring fluoride intake in 80 infants consuming infant formula
reconstituted with fluoridated
4. Further
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
5. Relevance
to the
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
b)
Is it practicable
for parents to provide a low fluoride infant formula for their young children?
6. Fluorosis
in the
In a recent briefing the British Fluoridation Society suggested that the
prevalence of unsightly dental fluorosis in the
The prevalence of dental fluorosis of aesthetic
concern in recent
|
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 |
Northumberland |
F NF |
3% 1% |
|
* Cochran et al (2004) |
8 |
1997 – 1998 |
Knowsley |
F NF |
4% 1% |
|
Tavener et al (2004) |
8 – 9 |
2001 - 2002 |
North-West |
NF |
1% |
|
* Whelton et al (2003) |
8 |
2001 - 2002 |
|
F NF NF |
4% 0% 0% |
|
Chadwick and Pendry (2004) |
12 |
2003 |
|
*** 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
The difference in prevalence of unsightly dental fluorosis in bottle-fed
as against breast-fed children in fluoridated districts in the
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 B)
·
that tooth
brushing with a smear or small pea sized amount of lower fluoride toothpaste
(500 ppm) should be started under supervision from the age of one year; and
·
that
fluoride tablets/drops should not be used.
References
American Dental Association (2006): Interim Guidance on Fluoride
Intake for Infants and Young Children 8 November 2006 http://www.ada.org/prof/resources/positions/statements/fluoride_infants.asp Accessed 22 February 2007.
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
Chadwick B, Pendry L (2004): Children's
dental health in the United Kingdom 2003. Non-carious dental conditions.
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.
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.
ANNEX A
From
American Dental Association website http://www.ada.org/prof/resources/positions/statements/fluoride_infants.asp
(Accessed 22 February 2007)
Interim Guidance on Fluoride Intake for Infants and Young Children
Recent studies
cited in the report of the National Research Council (NRC), “Fluoride in
Drinking Water: A Scientific Review of EPA’s Standards,” have raised the
possibility that infants could receive a greater than optimal amount of
fluoride through liquid concentrate or powdered baby formula that has been
mixed with water containing fluoride during a time that their developing teeth
may be susceptible to enamel fluorosis.
The
appropriate amount of fluoride is essential to prevent tooth decay. But
fluoride intake above optimal amounts can create a risk for enamel fluorosis in
teeth during their development before eruption through the gums.
Enamel
fluorosis is not a disease but rather affects the way that teeth look. Most
cases of fluorosis result in faint white lines or streaks on tooth enamel that
are not readily apparent to the affected individual or the casual observer.
While more
research is needed before definitive recommendations can be made on fluoride
intake by bottle-fed infants, the American Dental Association (ADA) issues this
interim guidance because we know that parents and other caregivers are
understandably cautious about what is best for their children.
The
Parents and
caregivers should consult with their pediatrician, family physician or dentist
on the most appropriate water to use in their area to reconstitute infant
formula. Ask your pediatrician or physician whether or not water used in infant
formula should first be sterilized.
The
The
As the leader
of a science-based profession, the
November 8, 2006
ANNEX
B
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
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 £1.28 per litre (local Tesco price).
3. Prices for the ready-to-use variety (1.3 above) are around £1.56 per litre (local Tesco price).
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 20p per litre. 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
15-Feb-07
* this briefing will be reviewed and updated in August
2007.