The US Public Government and the American Dental Association warn not to use fluoridated water for infant milk formula, and to avoid fluoride toothpaste for young children.
INTERIM GUIDANCE ON FLUORIDE INTAKE FOR INFANTS AND YOUNG CHILDREN
The US Public Health Service's Centers for Disease Control and Prevention, and the American Dental Association, released a recommendation in November 2006 that infant formula NOT be made with fluoridated water, following the NRC Review. The ADA states:
"If liquid or powdered concentrate infant formula is the primary source of nutrition, mix with water that is fluoride free, including water that is labeled purified, demineralized, deionized, distilled or reverse osmosis filtered water."
Why is this important?
The ADA's warning is extremely important because:
- Fluoride exposure during the first year of life increases the risk of dental fluorosis far more than at any other age.
- The risk is as much to the permanent teeth as it is to the "baby teeth".
- Fluorosis weakens the teeth and causes decay.
- Fluorosis can require ongoing expensive dental treatment - that you have to pay for.
- Fluorosis has psychological effects causing self-conscioussness resulting in reduced social interaction and employment success.
- It is internationally accepted that dental fluorosis is the first outward sign of fluoride poisoning.
The NZ Ministry of Health is trying to deny the application of the ADA’s warning in NZ and four false grounds:
- The first ground is that it is claimed the maximum level of fluoride allowed in infant formula was set with the 1ppm level in water in mind. Information obtained under the Official Information Act demonstrates that this is an outright lie: the level was set on zero-fluoride water. Moreover, not only does the MoH not provide evidence that the levels in infant formula allowed in the USA are any different from NZ (in fact the US levels are lower than NZ), but this is irrelevant since the overdosing of fluoride is caused by the fluoridated water alone, without considering the fluoride level in the formula. In fact the Minsitry had not vene looked at this information before making its false statement to the public! This untrue claim is analysed in detail below.
- The MoH claims the warning is due to the EPA’s (not the ADA’s) maximum contaminant level of "natural" fluoride of 4ppm in US water supplies. The CDC and ADA state, however, that its warning relates to "optimally fluoridated" water (0.7 – 1ppm; maximum 1.5ppm, the same as NZ). Moreover the same warning has come from both Australia (NHMRC Review 1999) and Ireland (Anderson et al 2004). Both these countries fluoridate at the same levels as NZ, in fact some parts of Australia are lower. Full marks to Lois Williams of National Radio for exposing this lie by none other than Martin Lee, during a radio item on the Far North debate. Also, the CDC dvises that less than 1/2 % of Americans drink water of more than 2ppm, let alone 4ppm.
- That it is only through fear of lawsuits, as the Americans are very litigious unlike New Zealanders. Firstly this implies that harming citizens is OK so long as they are not likely to sue you. Secondly, if the first claim (above) were true the warning would be issued by the EPA, who would be named in lawsuits, not the ADA. Thirdly, the point is that there is a legitimate case in tort for this harm, which is not just forseeable but a known consequence of fluoridation.
The warning was made in respect of both "optimally fluoridated" water supplies and, of course, those US communities with similar or higher levels of naturally occurring fluoride. The CDC web site makes the warning in relation to:"tap water [that] is fluoridated or has substantial natural fluoride (0.7 mg/L or higher)"
and, on both the CDC and ADA sites, that infant formula:"be mixed with water that is fluoride free or contains low levels of fluoride to reduce the risk of fluorosis. Examples are water that is labelled purified, demineralized, deionized, distilled or reverse osmosis filtered water."
Could it be any plainer?
- That a Southland study has shown no increase in dental fluorosis in New Zealand since studies in the 1980s, without advising that the 1980s studies showed unacceptably high levels of fluorosis. (fluoridation had reached its peak implementation level by the early 1970s). What the Ministry doesn't say is that those studies showed an unacceptable level of fluorosis.
25 percent of children had dental fluorosis in fluoridated Auckland and around 3 percent had the severer forms (Colquhoun, 1984). This was confirmed by pro-fluoridationist Dr Terry Cutress in 1985 (published in the NZ Dental Journal) who consequently recommended lowering the water fluoride level to below 1 ppm.
Also a 10% increase in dental fluorosis was known to occur when fluoride levels were increased to 1ppm, from H Trendley Dean’s original studies that started fluoridation, and on which the 1ppm level was set; acceptable collateral damage.
The York Review (2000) found that 56% of fluoridated populations suffer from dental fluorosis, and 8% of this is "more than cosmetic". This applies to all fluoridated communities in countries equivalent to NZ – USA, Canada, Australia, and Ireland (an officially-reported sevenfold increase in fluorosis since 1984, during which time New Zealand, with the most demographically similar population in the world, has allegedly experienced none).
Dental fluorosis inflicts considerable expense on individuals. It now costs more to treat dental fluorosis in the USA than it does to treat tooth decay. To date this has been met by the individual victims. We do not believe it is either fair or realistic to expect this to continue indefinitely. Such people have a arguable claim against those who implement fluoridation, or official bodies who actively promote fluoridation as safe for all subgroups of the population. Those New Zealanders harmed by Agent Orange and Dioxin provide an example of what may be expected in future regarding fluoridation.
Dental Fluorosis also has psychological effects, causing a reduction in social confidence and employability. For example, South Australian children 10- to 17-years-old were able to recognise very mild and mild fluorosis, and register changes in satisfaction with the colour and appearance of teeth. Even mild changes were associated with psychological and behavioural changes, such as embarrassment of teeth or self consciousness because of the appearance of the teeth. The most dramatic finding of this study was the psycho-behavioural impact was similar to that of crowding and overbite, both considered key disfigurements driving the demand for orthodontic care. See: Spencer AJ, Slade GD, Davies M. Water fluoridation in Australia. Community Dent Health. 1996 Sep;13 Suppl 2:27-37.
Analysis of the Ministry's primary claim (#1 above)
The "justification" claimed was based on three misleading implications:
- that the Standard (2.9.1) was set on the assumption that fluoridated water would be used.
- that fluoridated water alone was not the problem;
- that baby formula in the US had much higher levels of fluoride than formula available in New Zealand.
All these are untrue:
- The risk from fluoride was raised in the Public Health Commission’s 1995 report on fluoridation, which mistakenly assumed that lowering the fluoride level of the powder would remove the risk. Subsequently, the NZ-Australian standard for fluoride levels in infant formula (2.9.1) was reviewed and reported on in 1999 (Proposal 93). The review (supplied by NZFSA) identified that the amount of fluoride in the water alone posed the risk, even with no fluoride in the powder, or if fluoridated water itself were given to a baby. It considered 0.5 mg/litre (ppm) total to be the maximum safe level. Participants in the 3rd International Workshop on Fluorosis Prevention and Defluoridation of Drinking Water, 2000, run in conjunction with WHO, also considered 0.5 ppm to be the maximum safe level, and possibly less.
In fact the standard was based on using fluoride-free (distilled) water. Specifically, the report behind the standard (P93) states:
"[The advisory] statement on infant formula labels [to consult a doctor about the risk of dental fluorosis if the set level (0.17mcg/100KJ) was exceeded] was proposed for infant formula powders containing levels above 0.5 mg/L when reconstituted with fluorine free water.” (emphasis added) “At the levels given the formula may not cause dental fluorosis if prepared with water that has been distilled. However, if used with fluoridated water it may cause fluorosis."
The report goes on to reiterate the point:
"Sources of products that may contribute to excess fluoride ingestion in infants are fluoridated water, infant formula (reconstituted with optimally fluoridated water), …" and: "An Australian study (Silva & Reynolds, 1996) concluded that prolonged consumption (beyond 12 months) of infant formula with water fluoridated at 1ppm could contribute to dental fluorosis."
This essentially repeats the ADA's warning on not using fluoridated water for reconstituting infant formula, but at an even lower level of exposure, and for precisely the same reason: risk of dental fluorosis.
The report makes it clear that above the maximum allowed level (0.5 mg/l made up), infant formula itself is likely to cause fluorosis even if made with fluoride-free water, hence the mandatory warning. Fluoridated water can add almost twice this level again to the made up formula. If this level of fluoride was in the formula powder a warning would be required. Consequently, to be consistent with the health protection intent of Standard 2.9.1, parents should be warned not to feed their infants this level of fluoride; that is, not to make up formula with fluoridated water.
The report also states:
"The tolerable daily intake (TDI for adults) for contaminants [including fluoride] is not considered to be applicable to infants under 3 months of age [as the normal gastrointestinal and liver functions are not fully developed in infants]." and "It is unlikely that data will become available to establish safe levels of exposure for infants."Secondly, the fluoridated water alone overdoses the baby, as shown below, even if there were no fluoride in the formula. This is specifically confirmed by the following statement by Professor John Stamm, spokesman for the American Dental Association, and William Maas, the Oral Health Director for the Centres for Disease Control and Prevention: "The issue isn't the infant formula itself, but the [fluoridated] water it's reconstituted with"The claim that fluoridated water was allowed for when setting the fluoride levels of infant formula is a logical impossibility.
Thirdly, USA infant formula has the lowest levels of fluoride in the world. The ADA's warning was based on the findings of the National Research Council, whose report was published in 2006. The true figures for US formula are quoted at page 30 of that report:
| Country of origin | Level |
| USA | 0.23 mg/l |
| Canada | 0.9 mg/l |
| New Zealand (max permitted) | 1.5 mg/l |
| Country of origin | Level when reconstituted with distilled water |
| USA - industry standard* | 0.15 ppm |
| USA - actual | 0.14 ppm |
| NZ maximum# | 0.49 ppm |
| Australia actual 1999 | Up to 0.53 ppm |
*The legal limit is 0.4 ppm, however the industry has adopted a tighter standard
#The fluoride level for infant formula powder in NZ is 0.17 mcg per KJ (MoH press release). Infant formula typically contains 2900 KJ per litre when reconstituted (127 gm formula powder per litre). This equates to 0.49 mg fluoride per litre before considering the fluoride in the water. 900 ml water is required, adding another 0.9 mg fluoride, making a total of 1.39 mg per litre.
This demonstrates clearly the Ministry's deliberate deception. In fact the warning is even more relevant to NZ (and Australia, where that Ministry has made the same misleading statement) than the USA. As such the Ministry is in breach of its statutory duty under the Health Act. Any DHB trying to negate the ADA’s statement is also in breach of its statutory duty.
The recommended fluoride limit for children from o to 6 months is zero; the limit for 6 months to 3 years is 0.25 mg/day. The intake when fluoridated water alone is given to infants, let alone with the fluoride added from the formula, significantly exceeds this level.
The ADA is the leading promoter of water fluoridation, and referred to as a world authority by the Ministry when wanting support for its pro-fluoride position. Suddenly the Ministry wants to ignore its own "authority" when the ADA make a statement the Ministry doesn’t like!
Let's now take a closer look at the Ministry's press release:
Ready to drink formula is allowed 1.5ppm fluoride. This is the maximum allowed in NZ public water supplies, and more than the level the ADA states is unsafe for milk formula.
The Ministry also states:
"Labels on packages of infant formula product that contain the above levels of fluoride must indicate that consumption of the formula has the potential to cause dental fluorosis."This confirms the position of the ADA!
Moreover, 1.5 mg/litre fluoride is twice the recommended concentration for adults (0.7 mg/l), and higher than the level of "optimally fluoridated" water the ADA warns should not be used (0.7 – 1ppm)! Clearly the limit set by the NZ MoH for liquid formula is unsafe and must be reduced immediately! This is no way contradicts the ADA’s recommendation. It simply establishes that the MoH is determined to bury its head in the sand rather than admit it has got fluoridation policy wrong!
This also establishes, in our view, legal liability of the MoH for fluorosis caused by consumption of formula made within their allowed limits. Recommending that parents "[discuss this] with a medical practitioner or other health professionals" not only does not absolve the MoH of responsibility, but seems an admission that their limit is not safe – so why did they set it?
Councils Must Warn their Residents
It is our position, in light of the ADA's announcement, that all Local Councils fluoridating their water supplies must:
- Warn residents not to use tap water to make up infant formula, both in rates notices and prominently on their web sites
- Make unfluoridated water available to affected residents at the Council's cost.
Failure to at least warn parents of infants will found legal liability for subsequent dental fluorosis: parents will have strong grounds for suing Councils for adding fluorode and failing to issue warnings, resulting in harm and expense.
Position of the US Centres for Disease Control and Prevention
The CDC recommends the following requirements for water 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." (emphasis added)
Note: This confirms, as above, that the fluoride levels in premixed infant formula in the US is lower than the level allowed by the MoH in NZ. This again negates the claims about the ADA's position not being relevant to NZ. Also, this is further evidence in our view that the MoH's position is in dereliction of their statutory obligations under the Health Act, and renders them liable to legal claims for damages regarding fluorosis.
Significance of the Announcement
The significant point about this announcement is, of course, it is the first sign time the ADA has resiled from its position of "perfectly safe" ? is this the first brick in the next "Berlin Wall"?
Fluoride Toothpaste
"Parents and caregivers should 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 age 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."
Meanwhile the totally irresponsible NZ Dental Association promotes leaving fluoreide toothpaste on childrens teeth, "chewing it" and eventually swallowing it! This of course can cause a "spike" in fluoride levels in the blood sufficient to cause Central Nervous System damage!
A study from Ireland confirms why infants should not be given formula reconstituted with fluoridated tap water.
Anderson WA, et al. (2004). "A probabilistic estimation of fluoride intake by infants up to the age of 4 months from infant formula reconstituted with tap water in the fluoridated regions of Ireland." Caries Research 38: 421-9.
The study includes the following: "About 5% of 4-month-old infants are receiving SIX times more fluoride from formula (> 1.43 mg/day) than recommended for 6 month - 3 year olds (0.25 mg/day), and THREE times more fluoride than recommended for 3 to 6 year olds (0.5 mg/day)" (See: "Dosage schedule for dietary fluoride supplements" Journal of Public Health Dentistry 59: 203-204 (1999).
This supports the Food Safety Authority of Ireland’s call in October 2001:
"The scientific committee agrees that the precautionary principle should apply and recommends that infant formula should not be reconstituted with fluoridated tap water"
This call is in turn supported by recent studies which have found that consumption of fluoridated formula is strongly linked to an increased incidence of dental fluorosis - Brothwell D, Limeback H. (2003). Breastfeeding is protective against dental fluorosis in a nonfluoridated rural area of Ontario, Canada. Journal of Human Lactation 19: 386-90:
When infants are formula-fed, parents should be advised to reconstitute or dilute infant formula with deionized water (reverse osmosis, distilled, or low-fluoride bottledwater) in order to reduce the amount of systemically ingested fluoride.”Dr Limeback is Head of Preventive Dentistry Toronto University
See also Marshall TA, et al. (2004). Associations between Intakes of Fluoride from Beverages during Infancy and Dental Fluorosis of Primary Teeth. Journal of the American College of Nutrition 23:108-16.
The NHMRC Review also recommended fluoridated water not be used for infant formula in 1999, for the same reason.( Review of Water Fluoridation and Fluoride Intake from Discretionary Fluoride Supplements (National Health and Medical Research Council of Australia, Melbourne, 1999), 9)
Again, fluoride tablet bottles state that fluoride should not be given to infants (under 3 years old)
| Age (wks) | Milk/day(mls) | Fluoride at 1 ppm (mg/day) | Fluoride from formula at 1.39 ppm (mg/day) |
|---|---|---|---|
| 2 | 600 | 0.6 | 0.83 |
| 4 | 750 | 0.75 | 1.04 |
| 8 | 825 | 0.825 | 1.15 |
| 16 | 1600 | 1.6 | 2.22 |
| 24 | 875 | 0.875 | 1.2 |
*(See: "Dosage schedule for dietary fluoride supplements" Journal of Public Health Dentistry 59: 203-204 (1999).
 |
 |
