The use of fluoridated water in infant formula is in the news. Yesterday, Reuters published an article on a study from the Journal of the American College of Nutrition which found that consumption of beverages (particularly infant formulas reconstituted with fluoridated water) is associated with an increase of dental fluorosis in a baby’s primary teeth.

Reuters’ article comes on the heels of a press release issued by the New York State Coalition Opposed to Fluoridation (NYSCOF) addressing the same study.

While the authors of the study do not overtly challenge fluoridation policy, they do tip-toe into interesting terrain: namely, the potential need to restrict the use of fluoridated water in infant formula. To quote:

“Our results suggest that the fluoride contribution of water used to reconstitute formulas increases risk of fluorosis and could be an area for intervention.”

“Supporting long-term lactation could be an important strategy to decrease fluorosis risk of primary teeth and early developing permanent teeth.”

“Fluoride concentrations of both human milk (0.005–0.010 ppm) and cows’ milk (0.03–0.06 ppm) are low, and consumption of either human milk or cows’ milk could decrease fluorosis risk.”

Recent Controversy in Ireland

To put these findings in some context, it bears noting the recent experience in Ireland.

When Ireland’s Minister of Health convened “The Fluoridation Forum” to review Ireland’s mandatory fluoridation policy, the Forum asked the Food and Safety Authority of Ireland (FSAI) to conduct a risk assessment on fluoride.

In the FSAI’s initial risk assessment, they concluded:

“The scientific committee agrees that the precautionary principle should apply and recommends that infant formula should not be reconstituted with fluoridated tap water.“

The FSAI’s Scientific Committee voted unanimously (with 9 out of 15 committee members present) to adopt this recommendation at its October 3, 2001 meeting. Soon thereafter, on October 18, 2001, the FSAI’s Wayne Anderson presented the FSAI’s conclusions to the Minister’s Fluoridation Forum.

However, in the week following Anderson’s presentation to the Forum, some of the 6 FSAI’s Committee members who were not present at the October 3rd vote, began calling for a retraction and re-examination of the report’s conclusions.

Thus, despite the fact that the Committee vote adopting the report was unanimous, the FSAI retracted the report, stating that there were “some errors and that it didn’t necessarily take account of all of the science that was there.”

However, another potential reason why the FSAI may have retracted the report, became quite evident at a July 10, 2003 parliamentary hearing in Dublin.

At the hearing, it was revealed that Ireland’s leading fluoridation promoter, Dr. Joe Mullen (who was also a member of the Fluoridation Forum) believed that the FSAI’s initial conclusion may have meant the end to water fluoridation in Ireland.

According to Dr. Mullen’s testimony:

“I think it would probably have meant a serious re-evaluation, it probably would have meant the end of water fluoridation and at the very least a serious re-appraisal of it.”

Mullen’s appraisal was later seconded by Dr. Wayne Anderson of the FSAI, under questioning from the parliamentary committee members. Here is the exchange:

John Gormley (Panel Member): “Do you not accept that if that report, the original report, had been accepted that that was the end of water fluoridation in Ireland?”

Wayne Anderson (FSAI): “I don’t actually know the full details of how that would have effected it. I think we would be speculating. But I would have suggested, rather like Joe (Mullen), that it would have had a serious effect on it. There is no doubt about that. And that’s why it was very important we got the report correct scientifically.”

John Gormley: “It is very convenient.”

Chair of Committee: “Quite a turn-around.”

In the Irish Times article discussing this hearing, panel member John Gormley (the Chair of Ireland’s Green Party and former Mayor of Dublin) was quoted as saying:

“This is clearly a pivotal matter, as even those who came before the committee admitted that had the initial report been approved, it would have meant the end of water fluoridation in Ireland,” he said.

Implications for Water Fluoridation

As can be gleaned from this controversy, the recommendation that fluoridated water not be used for infant formula, has potent implications on the policy of mass water fluoridation.

Imagine, for instance, the logistics involved for governments to ensure that parents in fluoridated communities not use fluoridated water in infant formula. How will parents access the fluoride-free water? Who will bear the cost of purchasing it? How will parents react to the hassle and cost of not being able to use their own tap water?

Adding to the importance of not using fluoridated water in infant formula is another recent study, from the Journal of Human Lactation, which reports that breast-feeding is – as would be expected – protective against dental fluorosis (see abstract below).

Based on these findings, the authors of the study conclude that:

“dental professionals should support efforts to increase the rate and duration of breastfeeding.”

Translated this reads: Dental professionals should discourage parents from adding fluoridated tap water to their infant’s formula.

Simple advice, but if you follow its logical implications, a major liability to the continuation of the anachronistic fluoridation program.

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Journal of Human Lactation 2003 Nov;19(4):386-90.

Breastfeeding is protective against dental fluorosis in a nonfluoridated rural area of Ontario, Canada.

Brothwell D, Limeback H.

Community Dentistry, Faculty of Dentistry, University of Manitoba, Winnipeg, MB, Canada.
To determine the relationship between early infant feeding and dental fluorosis in a non-fluoridated area, 1367 children were examined for fluorosis and given a water sample vial and questionnaire. 752 families responded (55%). Breastfeeding was reported by 69% of respondents, with 53.6% breastfed < 6 months, 35.3% 6-12 months, and 11.1% > 1 year. Formula feeding was reported by 84% of respondents, with 60.3% and 39.7% formula fed for < 1 year and > 1 year, respectively. Fluorosis prevalence was 23.3% and was present in 27.2%, 19.6% and 13.8% of children breastfed for < 6 months, 6-12 months, and > 12 months, respectively (P < .05). About 87% of formula fed children had tap water added to the bottle. Breastfeeding for > 6 months may protect children from developing fluorosis in the permanent incisors. This study suggests that dental professionals should support efforts to increase the rate and duration of breastfeeding.