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By Stacie Crozier

The ADA has developed interim guidance on fluoride intake by infants and young children for parents, caregivers and health care professionals of infants who consume infant formula.

Recent developments led the Association to offer interim guidance on infant formula and fluoride while more research is conducted, said Dr. Daniel M. Meyer, associate executive director, ADA Division of Science.

Those developments include the U.S. Food and Drug Administration's health claim notification Oct. 14 allowing bottlers to claim that fluoridated water may reduce the risk of dental cavities or tooth decay, but not make the claim for bottled water products specifically marketed for use by infants, and the March 22 release of the National Research Council report: "Fluoride in Drinking Water: A Scientific Review of EPA's Standards."

"We understand that parents and other caregivers need to make informed choices, with the help of their family physician and dentist, about what is best for their children," Dr. Meyer said. "We want to help ensure that infants receive an optimal amount of fluoride. In some cases, infants may be getting a greater than optimal amount of fluoride through liquid or powder baby formula mixed with water containing fluoride."

The ADA interim guidance, Dr. Meyer added, notes that fluoride intake above recommended levels creates a risk for enamel fluorosis in teeth during their development before eruption through the gums.

Enamel fluorosis, a disruption in tooth enamel formation, occurs only during tooth development in early childhood. In its milder form, fluorosis appears as faint white lines or streaks on tooth enamel visible only to dental experts under controlled examination conditions. Noticeable white lines or streaks that often consolidate into larger opaque areas, which may become a cosmetic concern, characterize mild to moderate fluorosis.

"While more research is needed before definitive recommendations can be made on fluoride intake by bottle-fed infants," reads the guidance, "the American Dental Association issues this guidance because we know that parents and other caregivers are understandably cautious about what is best for their children.

"Parents, caregivers and health professionals who are concerned have some simple and effective ways to reduce fluoride intake from infant formula":

• feeding infants breast milk, widely acknowledged as the most complete form of nutrition for infants;
• for infants who get most of their nutrition from formula during the first 12 months, choosing ready-to-feed formula over formula mixed with fluoridated water to help ensure that infants do not exceed the optimal amount of fluoride intake;
• if liquid or powdered concentrate infant formulas is the primary source of nutrition, it can be mixed with water that is fluoride free or contains low levels of fluoride to decrease the risk of fluorosis, including water that is labeled purified, demineralized, deionized, distilled or reverse osmosis filtered water (many grocery stores sell these types of drinking water for less than $1 per gallon);
• the occasional use of water containing optimal levels of fluoride should not appreciably increase a child's risk for fluorosis.

Parents or caregivers should consult with their pediatrician or family physician on the most appropriate water for infants that is available in each area and whether that water should be sterilized when mixed with the type of infant formula that is used.

The guidance also offers additional guidance on other sources of fluoride for young children, including fluoride toothpaste, fluoride mouthrinse and dietary fluoride supplements.

"We all agree that the appropriate amount of fluoride is essential to prevent tooth decay, but at the same time we want to reduce the risk of enamel fluorosis as much as possible," said Dr. John Luther, associate executive director, ADA Division of Dental Practice.

The ADA guidance encourages parents/caregivers "to ensure that young children use an appropriate size toothbrush with a small brushing surface and only a pea-sized amount of fluoride toothpaste at each brushing. Young children should always be supervised while brushing and taught to spit out rather than swallow toothpaste. Many children under the age of six have not fully developed their swallowing reflex and may be more likely to inadvertently swallow fluoride toothpaste. Unless advised to do so by a dentist or other health professional, parents should not use fluoride toothpaste for children less than two years of age."

The guidance also notes that fluoride mouthrinses and dietary fluoride supplements should not be used for young children unless recommended by a dentist or other health professional and that people living in areas where naturally occurring fluoride levels in drinking water exceed 2 parts per million should consider an alternative water source or home water treatments to reduce the risk of fluorosis for young children.

The optimal fluoride level in drinking water is 0.7–1.2 parts per million, an amount which has been proven beneficial in reducing tooth decay. Naturally occurring fluoride may be below or above these levels in some areas. Under the Safe Drinking Water Act, the U.S. Environmental Protection Agency requires notification by the water supplier if the fluoride level exceeds 2 parts per million.

The ADA continues to endorse fluoridation of community water supplies as safe and effective for preventing tooth decay. The CDC also endorses water fluoridation and has called it one of 10 great public health achievements of the 20th century. Water fluoridation protects individuals of all ages and is more cost-effective than other forms of fluoride treatments or applications.

Some 170 million people in the U.S. are served by public water systems that are fluoridated. The ADA, along with state and local dental societies, continues to work with federal, state and local agencies to increase the number of communities benefiting from water fluoridation.

Last month's decision by the FDA to allow bottlers to use health claims on fluoridated water was welcomed by the ADA. It allows manufacturers to promote the benefits of optimally fluoridated water, improve consumer understanding of its benefits and enable consumers to better identify bottled-water products with optimal fluoride levels.

"Whether you drink fluoridated water from the tap or buy it in a bottle, you're doing the right thing for your oral health," said Dr. James B. Bramson, ADA executive director. "Thanks to the FDA's decision, bottlers can now claim what dentists have long known—that optimally fluoridated water helps prevent tooth decay."

The FDA cited scientific guidance from the CDC, the U.S. Public Health Service and the 2000 Surgeon General's Oral Health in America report supporting water fluoridation for caries prevention. The agency also said the claim is not intended for use on bottled water marketed to infants.

You can read the ADA's Interim Guidance: Information on Fluoride Intake for Infants and Young Children in the A-Z Professional Topic: Fluoride & Fluoridation.

ADA.org also offers more information on the FDA decision on bottled water; information on bottled water, home water treatment systems and fluoride exposure; fluoride and fluoridation; fluorosis, patient information and more.