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Fluoridation in New Zealand
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Fluoridation in New Zealand

Infant formula and fluoridated water

Introduction


A recent report of the United States National Research Council (NRC) called “Fluoride in Drinking Water: A Scientific Review of EPA’s Standards,” raised the possibility that infants could receive a greater than optimal amount of fluoride through liquid concentrate or powdered baby formula that has been mixed with water containing fluoride during a time that their developing teeth may be susceptible to enamel fluorosis.

Information about this issue is outlined below. There are some key differences between New Zealand and the United States. For instance in New Zealand the recommended range for optimal fluoride levels in drinking water is narrower, the upper limit is lower and NZ has lower strength fluoride toothpaste for children that is not available in the US. In New Zealand fluoride is not permitted as an additive to infant formula marketed here.

Fluoride in the water supply


Fluoride in drinking water at between 0.7 and 1 part per million reduces the level of tooth decay in all people with natural teeth.

Benefits of fluoridating the water supply


International research has indicated that the percentage of children with no decay is approximately 15 percent higher in areas with optimal levels of fluoride in the water, and New Zealand research indicates that decay levels are 30 to 40 percent lower in areas with optimal levels of fluoride in the water.

Below are pictures of a healthy child’s teeth and child’s teeth with dental decay.

Photo of a healthy child’s teeth. Photo of a child's teeth with dental decay.

Guidance available about the amount of fluoride we consume


In Australia and New Zealand the Nutrient Reference Values for Australia and New Zealand were published in 2006 by the National Health and Medical Research Council of Australia and the New Zealand Ministry of Health. This document sets recommended levels of fluoride intake for children and adults. The recommended upper level of intake of fluoride for children 0 to 6 months is 0.7mg/day and for children aged 7 to 12 months 0.9mg/day.

The upper level of fluoride intake is set as the average safe upper level if consumed at that amount daily. It is important to note that the upper limits are averages, and that the average applies over 6 month periods when infants will be consuming varying volumes of breast milk, formula and/or food.

Responsible agencies in New Zealand


The Ministry of Health and the New Zealand Food Safety Authority (NZFSA) have joint responsibility over this issue. The Ministry of Health has responsibility for setting standards and monitoring drinking water in New Zealand; the NZFSA has responsibility for monitoring the safety of food supply. Food Standards Australia New Zealand (FSANZ) is responsible for setting the food standards in the Australia New Zealand Food Standards Code (FSC).

Ministry of Health’s advice


It is important to note that the Ministry of Health promotes breastfeeding as the best source of food for infants. The Ministry of Health recommends that New Zealand mothers breastfeed their babies exclusively for the first four to six months of life, with continued breastfeeding until at least 12 months of age. If babies are not breastfed, the Ministry of Health recommends that an infant formula is used until 12 months of age. Updated advice for parents is planned for later this year and a draft document Food and Nutrition Guidelines for Healthy Infants and Toddlers Aged (0-2): A background paper will be released shortly for public consultation.

The Ministry of Health believes current New Zealand information indicates that appropriate steps are being taken to control fluoride intake in New Zealand. New Zealand information does not indicate that children are developing inappropriate levels of enamel fluorosis.

New Zealand Ministry of Health actions


The Ministry of Health is commissioning and monitoring ongoing New Zealand research into the amount of fluoride in New Zealand diets including testing of infant formulas, tooth enamel defects, and the levels of dental decay. The Ministry of Health is also monitoring ongoing international research and opinion about fluoride and infant formula.

This information will continue to be assessed and if new information suggests there is a need to change the amount of fluoride New Zealanders receive, the policies will be altered.

Enamel fluorosis


Tooth enamel fluorosis is one of a range of changes to tooth enamel. Living in an area with fluoridated water can increase the mild white flecks or streaks in the tooth enamel.

The following photos provide examples of normal teeth and the types of mild to moderate diffuse enamel fluorosis that is most commonly associated with water fluoridation. The most recent New Zealand information indicates that about 29 percent of 9-year-old children in Southland who had always received fluoridated water had these changes to the tooth enamel. This level had not changed since several earlier studies undertaken in the 1980s.


Normal dental enamel
Photo of Normal dental enamel.

Mild white spots on teeth - Mild diffuse enamel hypoplasia

Photo of Mild diffuse enamel hypoplasia.

Mild white spots on teeth - Moderate diffuse enamel hypoplasia

Photo of Moderate diffuse enamel hypoplasia.

Moderate white streaks associated with enamel fluorosis

Photo of Moderate white streaks associated with enamel fluorosis.

Other defects on teeth


Severe enamel fluorosis involves brownish defects to the tooth enamel which may also be pitted.

This form of enamel defect is uncommon in New Zealand. The most recent New Zealand information from 9-year-old children in Southland indicates that about 5 percent of children had similar defects.

These defects were just as common in children who had received fluoridated water as non-fluoridated water and the level of these defects had decreased about three fold from about 15 percent of children in the mid-1980s.

New Zealand guidelines limiting exposure to fluoride in water and in infant formula


The New Zealand drinking water standard recommends that the level of fluoride in water is adjusted to between 0.7 and 1 ppm to provide optimal protection from dental decay. The Maximum Acceptable Level of fluoride in drinking water is 1.5ppm.

Infant formula in New Zealand is regulated under Standard 2.9.1 of the Australia New Zealand Food Standards Code. Under this standard, fluoride is not permitted to be added to infant formula during the manufacturing process.

Companies manufacturing and selling infant formula in New Zealand must comply with the Australia New Zealand Food Standards Code. Further requirements also specify that an infant formula product must comply with this code where it contains
  • more than 17 micrograms of fluoride per 100 kilojoules prior to reconstitution, in the case of powdered or concentrated infant formula product
OR
  • more than 0.15 milligrams of fluoride per 100 millilitres, in the case of 'ready to drink' formula.

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 and recommend that the risk of dental fluorosis should be discussed with a medical practitioner or other health professionals.

Common sources of fluoride


Toothpaste is the other most common source of fluoride. Fluoridated toothpaste is available at two strengths in New Zealand. Regular fluoridated toothpastes contain 1000ppm fluoride. Child strength toothpaste containing 400-550ppm fluoride is marketed for children aged 0-6 years.

Regular twice daily toothbrushing with a smear of fluoride toothpaste is recommended for young children.

Excessive toothpaste consumption by young children can be associated with higher levels of enamel fluorosis. Young children should be supervised when toothbrushing, should spit out toothpaste after brushing and should not be allowed to eat toothpaste.

American Dental Association advice


The American Dental Association (ADA) issued an interim guidance statement about infant formula and fluoride intake in November 2006, following the United States National Research Council report. In that statement they acknowledged the appropriate amount of fluoride is essential to prevent tooth decay.

The American Dental Association also acknowledged that fluoride intake above optimal amounts can create a risk for enamel fluorosis in teeth during their development before eruption through the gums.

The ADA also noted that recent US research from the Center for Disease Control indicated a rise in the level of very mild or greater fluorosis in children and adolescents aged 16-19 years between 1988-94 and 1999-2004.

Based on that information, the ADA included in their interim guidance statement some simple precautionary advice for those parents, caregivers and health care professionals who may be concerned:

“If liquid concentrate or powdered infant formula is the primary source of nutrition, it can be mixed with water that is fluoride free or contains low levels of fluoride to reduce the risk of fluorosis…”

The ADA indicated that more research is needed before definitive recommendations can be made on fluoride intake by bottle-fed infants.

The ADA also stated:
“The ADA supports community water fluoridation as the single most effective public health measure to prevent tooth decay. It is a powerful strategy to reduce disparities in tooth decay among different populations and is more cost-effective than other forms of fluoride treatments or applications. Fluoridation is endorsed by the Centers for Disease Control and Prevention, which has listed community water fluoridation as one of 10 great public health achievements of the 20th century.”

Differences between New Zealand’s fluoride policies and America’s


In America the optimal level of fluoride recommended for drinking water is 0.7 to 1.2ppm and the maximum acceptable concentration is 2ppm. The upper limit of the optimal level and the maximum acceptable concentration are both higher that the New Zealand drinking water standards.

Toothpaste availability is different. In the United States all toothpaste contains 1000ppm fluoride or higher. No child strength toothpaste is available.

Australia’s advice


In 2006 the Australian Research Centre for Population Oral Health at the University of Adelaide published the conclusions of an expert workshop of fluoride use in Australia held in October 2005. That meeting considered the issue of infant formula and infant dietary fluoride levels in Australia. Recent Australian studies have not revealed any evidence of an association between consumption of infant formula and enamel fluorosis.

The Australian workshop concluded that:
  • while there had historically been some infant formula powders with high fluoride content, infant formula products now have very low levels of fluoride;
  • infant formula is safe for consumption by infants whether reconstituted with fluoridated or non-fluoridated water.


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