Flouride: Friend or Foe?

The author of the piece was concerned that she hadn’t been told flouridated water was inappropriate for use when mixing infant formula, in light of a 2006 study published in the Journal of the American Dental Association. This study looked at “associations between dental fluorosis (a condition that affects the enamel of developing teeth) and and fluoride intakes, with an emphasis on intake from fluoride in infant formula.” The researchers found that having “greater fluoride intakes from reconstituted powdered formulas (when participants were aged 3–9 months) and other water-added beverages (when participants were aged 3–9 months) increased fluorosis risk, as did higher dentifrice intake by participants when aged 16 to 36 months.” In plain language, there was a statistically significant correlation between drinking formula reconstituted with flouridated water and later flourosis, as well as between drinking other things which were mixed with flouridated water, and using too much flouride toothpaste.
There’s a couple of things to keep in mind with this issue. First of all, the concern over the flouride in infant formula is not about the formula itself; it’s about the water we use to make up the formula. According to the CDC:

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.

The CDC’s advice about the flouride/formula issue is a little contradictory; in one section it says that “For decades, parents have been mixing infant formula with optimally fluoridated tap water… and no association has been observed between infant formula use and an increased risk for moderate or severe fluorosis.” Yet another paragraph in this same section, it cites the ADA study I referenced above, as a “recent study (that) 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.”
So, should we worry or not? It’s not entirely clear, according to the CDC. When I started researching this issue, I figured there was no greater risk from using formula with flouridated water than from the other associated factors – like a toddler drinking water out of sippies, or slurping down too much Thomas the Train Toothpaste. But there does seem to be another piece of the puzzle: when you’re talking babies under nine months or so, pretty much ALL they are eating is formula. If you are using highly flouridated water, that’s an awful lot of flouride for a tiny, developing little system. So says the CDC:

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.

There’s no need to panic though; you can find out about the flouride levels in your tap water by calling your local ulility company or checking out  My Water’s Fluoride on the CDC Web site (this site only covers certain states, however). Since there are a lot of benefits to flouride in preventing tooth decay, many water systems have “optimally adjusted” the amount of flouride in the water; however, some contain heavier amounts than others. You can play it safe by using bottled water that is labeled purified, distilled, deionized, demineralized, or “reverse osmosis” – these are, by definition, lower in flouride. There are also ways to treat your water at home which can reduce flouride levels; or, if you can afford it, the ready-to-feed formulas don’t need additional water and have relatively low levels of flouride, so they are a good alternative, too. But don’t take out a second mortgage in order to switch to the premium stuff just for this reason…. as stated above, there’s only been one small study suggesting a link between powdered formula use and a MILD form of flourosis.
All in all, this is a minor problem, and an easy one to fix – nothing to lose valuable sleep over. But what I want to know is why the heck the water we used in the early days of FC’s bottle-feeding career – labeled “nursery water” – has extra flouride in it. If they’ve known since 2006 that this could be even a minor concern, you’d think they’d make “nursery water” low flouride. Weird, weird and weirder, don’t you think?
I’ll cover the whole to-boil-or-not-to-boil conundrum later this month, too. Beats me why the type of water we use in formula has to be such a complex issue, but I’ll get to the bottom of it, I promise.

Suzanne Barston is a blogger and author of BOTTLED UP. Fearless Formula Feeder is a blog – and community – dedicated to infant feeding choice, and committed to providing non-judgmental support for all new parents. It exists to protect women from misleading or misrepresented “facts”; essentialist ideals about what mothers should think, feel, or do; government and health authorities who form policy statements based on ambivalent research; and the insidious beast known as Internetus Trolliamus, Mommy Blog Varietal.

Suzanne Barston – who has written posts on Fearless Formula Feeder.


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21 thoughts on “Flouride: Friend or Foe?

  1. Ah, I'm so glad you said this! I had no idea. I started buying the nursery water specifically because my tap water has no fluoride (and is gross to boot). But now I'll just use the Poland Spring water. I'll drink the rest of the nursery water myself.

  2. I was told, when my babies were drinking formula, that we should make sure to use flouridated water, because well water does not contain fluoride. We have municipal water anyway, but the doctor did make a point to ask. When my babies were still being breastfed, she wanted me to give them flouride drops. I know I did with the first, can't remember if I bothered with the second.

    Bah…can't keep un. It seems like every time I turn around, there's a conflicting story about something.

  3. Our pediatrician warned us not to use nursery water owing to it's high and unregulated amount of flouride. We always remove chlorine and Floride with a Brita filter, so we were advised to make a few bottles a week with boiled plain tap water in order to expose our child to a little floride for the sake of his teeth.

  4. Interesting article. Apparently we have flouridated water (I guess I always assumed we did), but I had no idea it could potentially be a problem. We have a refridgerator with the water dispenser built in, and that is filtered. I guess my question is, if we use that water for bottles, does that take out the flouride? I'm pretty sure my parents used regular tap water with me (no clue if it was flouridated or not), and my dentist always remarks about how “beautiful” my enamel is. Creepy, in a dentist-compliment sort of way 🙂

  5. The pediatrician told us not to use the nursery water because of the Flouride. He recommended using distilled water instead.

  6. I just boiled my water. I got so confused on stuff like that so I just did what I thought I should do and had seen others do in the past. He's older now so I give him water in a sippy cup. I got non flouride tooth paste beacause I was told too, but I'm still not sure.

    I do know as a kid where we lived our water had too much flouride so my teeth have some white spots, it's not too bad though.

  7. I think the author of the About.com article was a little to dire with her title. G was primarily fed powdered formula, with some liquid concentrate and rtf. G also barely drank any straight water from the ages of 1to 3 ( we tried) and we used fluoride free toothpaste until recently for her.

  8. Does a Brita remove fluoride? We never boiled water for bottles, but we did put it through a Brita. Mostly because we prefer the way the water tastes when filtered, and on that and the grounds that filtered water for formula couldn't hurt anything, that's what we did.

  9. Another boiler of tap water for bottles here. Now that she's 100% on cow's milk (can't believe my baby is going to be a year old this week!!!!) we've retired the kettle and she's just getting regular filtered water in her sippy cups. I hope boiling the water was sufficient for any fluoride issues.

  10. Boiling water kills bacteria that sometimes (very rarely around our area) hang out in tap water, but it does not remove flouride and chlorine. A good filter gets out those two chemicals plus most microbes.

  11. I've never heard of Brita or other charcoal filters removing fluoride (and boiling will only concentrate it). If only it were that easy! As far as I know, you need a reverse osmosis system or something comparable.

    I would also be concerned with the fluoride content of formula (even without fluoridated water). Not sure if there are any that don't contain as high levels, but it would definitely be something to press the formula industry about fixing.

  12. Ok, since we're all ignorant of how to remove fluoride from water, I've looked it up:

    http://chemistry.about.com/od/chemistryhowtoguide/a/removefluoride.htm

    Boiling and Brita/Pur systems do NOT remove fluoride from tap water. This makes sense, boiling sterilizes the water, which may be important if your local water is contaminated and not safe to drink, however, boiling will concentrate, rather than remove fluoride. (also makes sense—when you boil water, you lose some in steam, but the fluoride will remain in the water in the pot, so less water in the pot=greater conc.of fluoride.)

    Also, Leanne C: FFF quotes the article above, the formulas do not have added fluoride. The nursery water does, but the formula itself is not the issue, with regards to fluoride.

  13. Formula still *contains* fluoride… at levels high enough to cause tooth damage in young infants and levels that are much, much higher than what is found in human milk. Some formulas contain less, but they all contain high levels compared to what is biologically normal for our species to consume

  14. @Leanne,

    I think that is somewhat debatable, if not inaccurate. Yes, there are higher levels of flouride in infant formula than in milk, but as the article referenced above from the CDC clearly states, these are LOW levels, and carefully controlled to be that way. The issue is the water people are using to reconstitute the formula; hence the CDC's recommendation for using RTF formulas (which are unfortunately cost-prohibitive).

    Sorry to be argumentative on this point, but I am all about truth, and I think parents should know what battles they need to pick and with whom.

  15. @Leanne-

    You know what? I just did some additional research and I take it back… it seems there ARE significantly higher levels of flouride in formula, according to the studies I found. However, it is not clear if they are using the term “formula” to mean reconstituted formula, or the powder alone… so I'm not entirely certain what the truth is here. However, I see where you came to your conclusion, and I apologize for not understanding that before.

    What also struck me as interesting in the 10 minutes I just spent looking through studies/policy papers is that flouride supplementation is encouraged for kids over 6 months old by major medical groups like the AAFP. They do mention flourosis, but the concern seems to be dental caries as well, esp for bottle-fed kids, which leaves us at a loss – are we getting too much flouride or not enough? How can formula feeding parents adequately protect their childrens' teeth?

    Frankly, I think we should all go with Fearless Husband's attitude towards oral hygiene in babies – “That's why this first set is only temporary.”

    LOL.

  16. This all seems much ado about nothing to me. Cavaties vs. mild flourosis I'll take flourosis! It's important to bring up with your pediatrician and to know the flouride levels in your water, but other than that, in the grand scheme of things, a non-issue for me.

  17. Gerber Water, slightly cheaper at Wal-mart, has no fluoride. My local water has very low levels so it's fine to use, but when we were on vacation I certainly couldn't check all the water across the country so I just bought Gerber baby water at Wal-mart after making sure it was fluoride free.

    Why do we want our kids not to have fluorosis? There are studies showing that if they have fluorosis then they are not absorbing calcium right, meaning weaker bones, meaning more broken bones, meaning osteoporosis eventually, etc. I also had a friend who had fluorosis on her teeth and it affected her self esteem terribly… really I would say it practically ruined her life. Crooked teeth people ignore, that is more fixed. But when you look like you have brown sediment permanently on your teeth?

  18. I came here looking to see if you had written about the flouride issue. I heard a report on it on the radio a few days ago and am doing some more research.

    I think that flourosis is one concern, but I also wouldn't freak out about it one way or the other since the teeth are temporary (“baby teeth”). However, the report I heard on the radio also mentioned other possible concerns.

    Here is a quote from the Flouride Action Network:

    “Dental fluorosis is not the only risk from early-life exposure to fluoride. A recent review in The Lancet describes fluoride as “an emerging neurotoxic substance” that may damage the developing brain. The National Research Council has identified fluoride as an “endocrine disrupter” that may impair thyroid function, while recent research from Harvard University has found a possible connection between fluoride and bone cancer. “

    http://www.fluoridealert.org/health/infant/

    I plan to do more research on this issue before posting about it on my blog, but thought I would pass this along in the meantime in case it is useful to anyone here.

    For what it is worth, we were never told to give flouride drops to our children and were told to avoid flouridated toothpaste until they are 2 years old. Our water doesn't have any flouride in it, which I am thankful for.

  19. Did you read about the changing recommendation levels? They've gone down, because of rising fluorosis. http://www.hhs.gov/news/press/2011pres/01/pre_pub_frn_fluoride.html Also, ingested fluoride has never been shown to improve teeth. It's fluoride exposure in the mouth (that's why you don't swallow the mouthwash.) Fluorosis is also one symptom of several, dental being the most viewable but not the most serious. Skeletal fluorosis is scary stuff. It doesn't happen often because you have to be exposed to high levels of fluoride, but it always bothers me when the government changes what level is safe by going LOWER than what they were telling me. http://www.who.int/water_sanitation_health/diseases/fluorosis/en/

    Fluoride treatments for infants is not recommended for babies under 6 months and there's argument on whether any formula fed baby needs them because it's believed they are getting quite enough fluoride as it is. Nursery water has .7ppm I think it is, which is the very top of the limit of intake and that's not taking into account that the powder has fluoride in it from the processing. Most bottle water also has unknown levels. Gerber has none, right now. I expect after the lowered recommended levels there may be more that will come out with no fluoride or very low levels. But, for instance, my local area fluoride is naturally high enough (and low enough not to be a concern) that we don't do supplements typically for kids. Keep in mind that fluoride is also in soda, juice, and SO many things that are around us that getting enough fluoride isn't as much of a problem anymore.

    I find a lot of “bottle fed babies get cavities” arguments are based on bad bottle feeding behavior as well. You don't let your child walk around all day carrying juice or milk, whether in a bottle or sippy cup. Let it be water. Don't put your baby to bed with a bottle, don't let them feed themselves. Everyone assumes we do in these studies, and when people don't their babies don't have as many teeth problems.

    http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/5/1113 As far as dental health, the AAP has a lot of recommendations on top of fluoride. Caries are typically caused by a germ, not sugary drinks, and if mom eats a bite of something then gives it to their baby and they have an open cavity that has not been treated then they are likely to pass it on. I watched an entire educational film about this (aimed at dentists) about how 'baby bottle rot' is not very likely to be caused by bottles but by exposure to open cavities in family members, daycare workers, and others. Fluoride protects a little bit (the enamel in that first set of teeth is very thin) but a better goal is just teaching people how to not spread these germs (including kisses) unless they have gotten their teeth cared for lately and don't have any open cavities.

    I err on the side of caution and avoid fluoride until they're older.

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