Background:
Infant Formula and the Risk for Enamel Fluorosis
The proper amount of fluoride from infancy through old age helps
prevent and control tooth decay. In a minority of children, fluoride exposure during the ages when
teeth are forming (from birth through age 8) also can
result in a range of changes within the outer surface of the tooth
called enamel fluorosis. Recent evidence suggests that mixing powdered
or liquid infant formula concentrate with fluoridated water on a regular
basis may increase the chance of a child developing the faint white
markings of very mild or mild enamel fluorosis. This occurs on baby and
permanent teeth while they are forming under the gums. Once the teeth
come
into the mouth, they are no longer able to develop this condition.
Typically, very mild or mild fluorosis is barely noticeable, if noticed at all. Studies have not
shown that teeth are likely to develop more esthetically noticeable
forms of fluorosis, even with regular mixing of formula with fluoridated
water.
In children younger than 8 years of age, combined fluoride exposure from
all sources—water, food, toothpaste, mouth rinse, or other
products—contributes to enamel fluorosis. Currently one-third (33%) of
children aged 12 to 15 years in the United States have very mild to mild
forms of this condition. It is important to understand that
some fluoride exposure to developing teeth also plays a long-term role in
preventing tooth decay. Parents and health providers should weigh the
balance between a child’s risk for very mild or mild enamel fluorosis and the benefit of fluoride
for preventing tooth decay and the need for dental fillings.
The possibility of an association between fluoride in infant formula and
the risk for enamel fluorosis has been studied for many years. Until now,
most researchers concluded that fluoride intake during a child's first 10 to12
months had little impact on the development of this condition in permanent
teeth. A recent study, however, has raised the possibility that fluoride
exposure during the first year of life may play a more important role on fluorosis development than was previously understood. It now
appears that
the amount of the fluoride contained in the water used for mixing infant
formula may influence a child’s risk for developing enamel fluorosis,
particularly if the child’s sole source of nutrition is from reconstituted
infant formula.
CDC will continue to assess the science regarding the use of fluoride in
preventing tooth decay while limiting enamel fluorosis, and will modify its
recommendations as warranted. CDC believes that community water fluoridation
is safe and healthy and promotes its use for people of all ages.
What is the best source of nutrition for infants?
Breastfeeding is ideal for infants. CDC is committed to increasing
breastfeeding rates throughout the United States and to promoting
optimal breastfeeding practices. Both babies and mothers gain many
benefits from breastfeeding. Breast milk is easy to digest and contains
antibodies that can protect infants from bacterial and viral infections.
More can be learned about this subject at
http://www.cdc.gov/breastfeeding/.
If breastfeeding is not possible, several types of formula are available
for infant feeding. Parents and caregivers are encouraged to speak with
their pediatrician about which type of infant formula is best suited for
their child.
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What type of water does CDC recommend for mixing infant formula?
Parents should follow the advice of the formula manufacturer and
their child’s doctor for the type of water appropriate for the formula
they are using. Parents and caregivers of infants fed primarily with
formula from concentrate who are concerned about the effect that mixing
their infant’s formula with fluoridated water may have in developing
enamel fluorosis can lessen this exposure by mixing formula with low
fluoride water most or all of the time. This may be tap water, if the
public water system is not fluoridated (check with your local water
utility). If tap water is fluoridated or has substantial natural
fluoride (0.7 mg/L or higher), a parent may consider using a
low-fluoride alternative water source. Bottled water known to be low in
fluoride is labeled as purified, deionized, demineralized, distilled, or
prepared by reverse osmosis. Most grocery stores sell these types of
low-fluoride water. Ready to feed (no-mix) infant formula
typically has little fluoride and may be preferred for use at least some
of the time.
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Why is there a focus on infant formula as a source of fluoride?
Infant formula manufacturers take steps to assure that infant formula
contains low fluoride levels—the products themselves are not the issue.
Although formula itself has low amounts of fluoride, when infant
formula concentrate is mixed with fluoridated water and used as the
primary source of nutrition, it may introduce
fluoride at levels above the amount recommended to minimize the risk for fluorosis. Infants consume little other than breast milk or formula
during the first four to six months of life, and continue to have a high
intake of liquids during the entire first year. Therefore, proportional
to body weight, fluoride intake from liquids is generally higher for
younger or smaller children than for older children, adolescents, or
adults. Mixing concentrate with fluoridated tap
water on an occasional basis is unlikely to be of much risk. However,
when used consistently as the primary source of nutrition over longer periods of the first year, a child may
receive enough fluoride to increase his/her chances of developing very
mild or mild fluorosis.
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What types of infant formula may increase the risk for enamel
fluorosis?
There are three types of formula, including powder, which comes in
bulk or single serve packets, concentrated liquid, or ready-to-feed
formula. Ready-to-feed formula is more convenient, but also more
expensive. Powder formula is usually the least expensive, but requires
mixing with water, as does the liquid concentrate.
Ready-to-feed formula contains little fluoride and does not
contribute to enamel fluorosis. Those types of formula that require mixing with water—powdered or
liquid concentrates—can be the child’s main source of fluoride intake
(depending upon the water source) and may contribute to this condition.
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What is enamel fluorosis?
Enamel fluorosis is a hypomineralization of the enamel surface of the
tooth that develops during tooth formation. Clinically, this appears as
a range of cosmetic changes varying from barely noticeable white lines
or spots to pitting and staining of the outer enamel layer. More
cosmetically objectionable forms of this condition can occur when young
children consume excess fluoride from all sources during critical
periods of tooth development. More can be learned
about enamel fluorosis at
http://www.cdc.gov/fluoridation/safety/enamel_fluorosis.htm.
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Should all parents consider mixing formula with water from sources
other than tap water?
There is no evidence that water containing low concentrations of
fluoride introduces a risk for enamel fluorosis in the developing teeth
of young children. Some tap water and most bottled water contain low
concentrations of fluoride. Mixing concentrate with fluoridated tap
water on an occasional basis is unlikely to be of much consequence.
For infants whose primary nutrition source is formula from concentrates,
parents should take into consideration the
fluoride concentration in their water source when making decisions about
mixing formula.
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How can I find out what the concentration of fluoride is in my tap
water?
The best source of information on fluoride levels in your water
system is your local water utility. Other knowledgeable sources may be a
local public health authority, dentist, dental hygienist, or physician.
My Water’s Fluoride on the CDC Web site
allows consumers in currently participating states to learn the
fluoridation status of their water system. Nearly all tap water contains
some natural fluoride, but, depending on the water system, the concentration can
range from very low (0.2 mg/L fluoride or less) to very high (2.0 mg/L
fluoride or higher). Approximately 69% of all public water systems
serving about 184 million people have optimally adjusted fluoride in
their water—that is between 0.7 and 1.2 mg/L fluoride.
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My city has community water fluoridation (adjusted fluoride in the
public water supply). Is it safe to use this tap water for my baby?
Water fluoridation is safe, effective, and healthy. Water fluoridated
at a level optimal for oral health poses no known health risks for infants. However, some children may develop enamel fluorosis,
a cosmetic condition. All persons should know whether the fluoride
concentration in their primary source of drinking water is below optimal
(less than 0.7 mg/L fluoride), optimal (0.7–1.2 mg/L fluoride), or above
optimal (greater than 1.2 mg/L fluoride). Use of water below 0.7 mg/L
fluoride contributes to a very small risk of developing this
condition. The
risk increases with an increasing level of fluoride and depends on other
factors, such as age and weight of the child and how much formula they
drink each day. Knowledge of the fluoride level in the drinking water is also the basis for other individual
and professional decisions regarding use of fluoride products by
children, such as fluoride toothpaste, mouth rinses, or dietary supplements. In
addition, people living in areas where naturally occurring fluoride
levels in drinking water are greater than 2 mg/L should consider an
alternative water source or home water treatments to reduce the risk of fluorosis for young children. Contact your local water company or
utility to learn the fluoride level in your water supply.
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Is all bottled water low in fluoride?
Most bottled water contains low fluoride concentrations; however,
much variation exists—some brands may contain optimal or higher
levels. Because there currently is no requirement to display the
fluoride concentration on bottle labels, you may need to contact the bottler
to learn the level of fluoride in bottled drinking water.
Certain types of bottled water are, by definition, always low in
fluoride and can reliably be used for mixing formula. Water
labeled as purified, distilled, deionized, demineralized, or produced
through reverse osmosis are always low in fluoride.
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Can mixing formula with optimally fluoridated tap
water cause moderate or severe fluorosis?
For decades, parents have been mixing infant formula with optimally
fluoridated tap water (a level determined by the U.S. Public Health
Service between 0.7 mg/L fluoride and 1.2 mg/L fluoride and maintained
by your water utility to maximize decay prevention and limit fluorosis
potential) and no association has been observed between infant formula
use and an increased risk for moderate or severe fluorosis. There is no
clear evidence that using infant formula from concentrates as the primary souce of nutrition increases a child’s chances of
developing the more severe forms of fluorosis; however, there may be an
increased risk for very mild to mild forms.
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Are children today at greater risk for developing fluorosis from
infant formula mixed with fluoridated water than children in the past?
Children today are at no greater risk of developing enamel fluorosis
from infant formula than children in previous generations. Little has
changed with regard to the amount of fluoride consumed or the
concentration of fluoride in the formula. There has always been some
level of very mild and mild fluorosis in children, but it was thought
to be caused by fluoride intake after age one. However, new evidence
indicates that fluoride exposure during the first year of life may play
a greater role in developing fluorosis than was previously thought, so
parents may consider reducing the potential for this condition by limiting
fluoride from this source.
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Will using only low fluoride water to mix formula eliminate the risk
for fluorosis?
Using only water with low fluoride levels to mix formula will not
eliminate the risk of enamel fluorosis. But following such a practice
may reduce the chance of fluorosis occurring. This condition
occurs among some children in all communities, even in communities with
a low natural concentration of fluoride in the water. Other factors that
contribute to developing fluorosis include swallowing of
toothpaste and use of dietary supplements that include fluoride (tablets
or drops). Learn more about
simple steps to take care of children’s teeth.
(PDF–170K)
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What can be done to reduce my child’s chance of developing fluorosis?
CDC has developed recommendations to reduce the risk for
enamel fluorosis. Remember, fluorosis
can only occur during the time of enamel formation, before the teeth
come into the mouth. Young children who use multiple
sources of fluoride such as fluoride toothpaste, dietary supplements, and water
with optimal or higher natural fluoride have a higher risk for this
condition. Community
water fluoridation is a safe, effective, and inexpensive way to prevent
tooth decay, and CDC recommends continuing and extending this practice.
Steps can be taken to reduce the potential for enamel fluorosis associated
with drinking water and other fluoride products. Learn more about
recommendations on how to reduce the risk for enamel fluorosis.
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Date last reviewed: August 28, 2009
Date last modified: August 28, 2009
Content source:
Division of Oral Health, National Center for Chronic Disease Prevention and
Health Promotion |
