Guidance for Use of Fluoridated Water for Feeding during Infancy

The New York State Department of Health concurs with the current scientific evidence that fluoride added to water is safe and effective in controlling tooth decay. In New York State, approximately 12 million people drink water containing one milligram of fluoride per liter. The department considers this level as the appropriate amount to maximize tooth decay prevention and minimize the risk of enamel fluorosis.

Enamel fluorosis that results from drinking fluoridated water is not a disease but rather affects the way teeth look upon close examination. Enamel fluorosis appears as a range of cosmetic changes varying from barely noticeable white markings to pitting and staining of the outer tooth enamel. Some reports have expressed concerns that the amount of fluoride contained in water used for mixing infant formula may influence the possibility of developing enamel fluorosis.

The New York State Department Health concurs with the Centers for Disease Control and Prevention (CDC) that water fluoridated at the optimum level poses no known health risks. Further, the department has concluded that the risk of enamel fluorosis associated with infant formula prepared with fluoridated water is low for several reasons:

  • The occurrence of advanced forms of enamel fluorosis is extremely rare in fluoridated communities even though some water systems have been fluoridating for over 50 years. Milder forms of enamel fluorosis are not noticeable.
  • The critical period for permanent tooth development when enamel fluorosis is most likely to occur, is later in life when children are less likely to be on infant formula.
  • The theoretical amounts of fluoride that might cause advanced forms of enamel fluorosis are reached with exclusive and/or excessive formula use for a prolonged period. According to the National Center for Education in Maternal and Child Health's Bright Futures Guidelines, infants should begin solid foods between four and six months, if they are developmentally ready. This will also reduce the exposure to excessive levels of fluoride.

The American Dental Association has issued interim guidance to reduce the possibility of developing enamel fluorosis (http://www.ada.org/prof/resources/positions/statements/fluoride_infants.asp). The department is awaiting the development of the final guidance. In the meantime, the department offers the following recommendations to concerned parents:

Tooth decay is the single most common chronic childhood disease. Appropriate amounts of fluoride are beneficial for preventing tooth decay. Fluoride intake above the recommended level for a child's age creates a risk for enamel fluorosis. There are some simple and effective ways to reduce excessive fluoride intake:

  • Breastfeeding for infants is strongly encouraged by the New York State Department of Health. The New York State Department of Health Breastfeeding Promotion Program provides training and guidelines to help get more mothers to breastfeed and to get them to breastfeed longer (http://www.nyhealth.gov/community/pregnancy/breastfeeding/). The WIC Program in the Division of Nutrition promotes and supports breastfeeding among its clients, through the work of lactation consultants and peer counselors in its centers.
  • If breastfeeding is not possible, parents and caregivers are encouraged to speak with a health care provider about which type of feeding is best suited for their child. The advisory for healthy feeding practice during a baby's first year is available at (http://www.fns.usda.gov/tn/resources/feeding_infants.html).
  • Solid foods should be introduced between four and six months of age, when the infant is developmentally ready. Change from formula to whole pasteurized milk at 1 year of age (http://www.brightfutures.org/bf2/pdf/pdf/Infancy.pdf).
  • Parents who are concerned about the risk of enamel fluorosis, can mix liquid concentrate or powdered infant formula with water that is fluoride free or contains low levels of fluoride. Examples are water that is labeled purified, demineralized, deionized, distilled or reverse osmosis filtered water. More information on this topic can be found at http://www.ada.org/public/topics/fluoride/infantsformula_faq.asp and http://www.cdc.gov/fluoridation/safety/infant_formula.htm.

The New York State Department of Health encourages parents and caregivers to consider the following when providing the best possible care for the infant:

  • Wipe an infant's teeth after feeding, especially along the gum line, with a soft cloth or soft bristled toothbrush.
  • Avoid putting the child to bed with a bottle or sippy cup.
  • Avoid saliva-sharing behaviors, such as sharing a spoon when tasting baby food, cleaning a dropped pacifier by mouth, or wiping the baby's mouth with saliva.
  • Do not use toothpaste with fluoride unless your infant's doctor or dentist recommends it.
  • Consult your health care provider about the dental needs of your child.

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