Proposal 4-Infants

WASHINGTON ACTION FOR SAFE WATER

October 4, 2010

Washington State Board of Health
Craig McLaughlin, Executive Director
Via e-mail:   McLaughlin, Craig D   (DOH) <Craig.McLaughlin@DOH.WA.GOV>

PETITION FOR RULE MAKING (#4) WAC 246-290-460

WATER FLUORIDATION,

PROTECTION FOR INFANTS

 

This petition is for the protection of the health of infants, our most vulnerable, with rule change under RCW 34.05.330.

I. PETITION TO PROTECT INFANTS WITH RULE MAKING ON FLUORIDATION CONCENTRATION.

 

This petition is made in the interest of protecting infants.

II. WASHINGTON STATE BOARD OF HEALTH’S AUTHORITY TO ESTABLISH RULES NECESSARY TO ASSURE SAFE WATER FOR INFANTS.

 

Pursuant to RCW 43.20.50 (1) “The state board of health shall provide a forum for the development of public health policy in Washington state . . . .”  RCW 43.20.50 (2) “In order to protect public health, the state board of health shall: (a) Adopt rules for group A public water systems . . . necessary to assure safe and reliable public drinking water and to protect the public health.

The AGO 1992 Opinion No. 17 states:

“2.  The Legislature has authorized the Board of Health to establish, and the Department of Health to enforce, a comprehensive regulatory scheme for public water systems.”

III. INFANT EXPOSURE TO FLUORIDE

Few scientists dispute the concept that mother’s milk for an infant is species specific and has the optimal nutrient composition for the infant. The American Academy of Pediatrics provides guidance for the Board of Health on determining the safe concentration of fluoride in alternative feeding methods such as infant formula made with water from public water systems.

Exclusive breastfeeding is the referenceor normative model against which all alternative feeding methodsmust be measured with regard to growth, health, development,and all other short- and long-term outcomes.”[1]

Concentration of fluoride in mother’s milk:

Dabeka et al. (1986) found detectable concentrations in only 92 of 210 samples (44%) obtained in Canada, with fluoride ranging from <0.004 to 0.097 mg/L. The mean concentration in milk from mothers in fluoridated communities (1 mg/L in the water) was 0.0098 mg/L; in nonfluoridated communities, the mean was 0.0044 mg/L).”[2]

Fluoride content in cow’s milk ranges from 0.007 to 0.068.

Other authorities state:

“In IAOMT’s ongoing examination of the toxicological data on fluoride, the Academy has made several preliminary determinations over the last 18 years, each concluding that fluoride added to the public water supply, or prescribed as controlled-dose supplements, delivers no discernible health benefit, and causes a higher incidence of adverse health effects.” http://www.iaomt.org/articles/category_view.asp?catid=34

“When formula concentrations need to be diluted, it is recommended parents use bottled water that is fluoride-free or low in fluoride water or tap water from a reverse osmosis home water filtration system, which removes most of the fluoride.”  Source: Academy of General Dentistry http://www.agd.org/public/oralhealth/Default.asp?IssID=303&Topic=F&ArtID=1247

“A major effort should be made to avoid use of fluoridated water for dilution of formula powders.”
SOURCE: Ekstrand J. (1996). Fluoride Intake. In: Fejerskov O, Ekstrand J, Burt B, Eds. Fluoride in Dentistry, 2nd Edition. Munksgaard, Denmark. Pages 40-52.

“If using a product that needs to be reconstituted, parents and caregivers should consider using water that has no or low levels of fluoride.”
SOURCE: American Dental Association (2006). Interim Guidance on Reconstituted Infant Formula. November 9, 2006.

“[I]nfant formulas reconstituted with higher fluoride water can provide 100 to 200 times more fluoride than breastmilk, or cows milk.”
SOURCE: Levy SM, Guha-Chowdhury N. (1999). Total fluoride intake and implications for dietary fluoride supplementation. Journal of Public Health Dentistry 59: 211-23.

“[P]arents of children using powdered infant formula should be warned by their medical practioners to use unfluoridated or defluoridated water to reconstitute the formula.”
SOURCE: Diesendorf M, Diesendorf A. (1997). Suppression by medical journals of a warning about overdosing formula-fed infants with fluoride. Accountability in Research 5:225-237.

“Our analysis shows that babies who are exclusively formula fed face the highest risk; in Boston, for example, more than 60 percent of the exclusively formula fed babies exceed the safe dose of fluoride on any given day.”
SOURCE: Environmental Working Group, “EWG Analysis of Government Data Finds Babies Over-Exposed to Fluoride in Most Major U.S. Cities”, March 22, 2006.

“[M]ore than 50 percent of infants are currently formula fed by 1 month of age, and these infants are likely to be continuously exposed to high intakes of fluoride for 9 or 10 months – a circumstance quite rare in the 1960s and early 1970s.”
SOURCE: Fomon SJ, Ekstrand J. (1999). Fluoride intake by infants. Journal of Public Health Dentistry 59(4):229-34.

“Fluoride is now introduced at a much earlier stage of human development than ever before and consequently alters the normal fluoride-pharmacokinetics in infants. But can one dramatically increase the normal fluoride-intake to infants and get away with it?”
SOURCE: Luke J. (1997). The Effect of Fluoride on the Physiology of the Pineal Gland. Ph.D. Thesis. University of Surrey, Guildford. p. 176.

“[F]luoride exposure, at levels that are experienced by a significant proportion of the population whose drinking water is fluoridated, may have adverse impacts on the developing brain… The findings are provocative and of significant public health concern.”
SOURCE: Schettler T, et al. (2000). Known and suspected developmental neurotoxicants. pp. 90-92. In: In Harms Way – Toxic Threats to Child Development. Greater Boston Physicians for Social Responsibility: Cambridge, MA.

“Infant foods mixed with water pose a special problem… One wonders what a 50-fold increase in the exposure of fluoride, such as occurs in infants bottle-fed with water-diluted preparations, may mean for the development of the brain and other organs… There is reason to be aware of the possibility that fluoride may affect the somatic and mental development of the child.”
SOURCE: Carlsson A. (1978). Current problems relating to the pharmacology and toxicology of fluorides. Lakartidningen 25: 1388-1392.

“The entire Board holds serious concerns about the current fluoride exposure of infants between the ages of zero and six months. We deem this exposure to be a “significant public health risk”, and one that should be given immediate attention by the city and state.”
SOURCE: Burlington Board of Health (Vermont, USA) August 31, 2005. See copy of full report.

Fluoride Supplementation No Longer Recommend for Newborns:

Fluoride Supplement Dosage Schedule – 1994*
(in mg of Fluoride per Day)
Concentration of F in Drinking Water (ppm)
Child’s Age <0.3 0.3-0.6 >0.6
Birth-6 months 0 mg/day 0 mg/day 0 mg/day

*Recommended by the American Dental Association, the American Academy of Pediatric Dentistry and the American Academy of Pediatrics.

“On January 31 and February 1, 1994, a Dietary Fluoride Supplement Workshop was held at the American Dental Association Headquarters in Chicago. The workshop was cosponsored by the American Dental Association (ADA), the American Academy of Pediatric Dentistry (AAPD), and the American Academy of Pediatrics (AAP). The workshop was convened because several reports had been published to show that the prevalence and, to a lesser degree, the intensity of dental fluorosis had increased in the permanent teeth of children of school age since the dosage for fluoride supplements were last revised by the three sponsoring organizations in 1979… Some of the major changes are:

“The recommended age to begin taking supplements is 6 months of age rather than at birth (previous ADA schedule) or at two weeks (previous AAP schedule). This change was made based on an assessment of risks and benefits.”
SOURCE: Anon. (1999). Dosage schedule for dietary fluoride supplements. Journal of Public Health Dentistry 59:203-204.

“Infants less than one year old may be getting more than the optimal amount of fluoride (which may increase their risk of enamel fluorosis) if their primary source of nutrition is powdered or liquid concentrate infant formula mixed with water containing fluoride… If using a product that needs to be reconstituted, parents and caregivers should consider using water that has no or low levels of fluoride.”
SOURCE: American Dental Association (2006). Interim Guidance on Reconstituted Infant Formula. November 9, 2006.

“A major effort should be made to avoid use of fluoridated water for dilution of formula powders. In addition, when economically feasible, young infants fed formulas prepared from concentrated liquids should have these these formulas made up with nonfluoridated water.”
SOURCE: Ekstrand J. (1996). Fluoride Intake. In: Fejerskov O, Ekstrand J, Burt B, Eds. Fluoride in Dentistry, 2nd Edition. Munksgaard, Denmark. Pages 40-52.

“[W]e recommend use of water with relatively low fluoride content (e.g. 0 to 0.3 ppm) as a dilutent for infant formulas and recommend that no fluoride supplements be given to infants.”
SOURCE: Fomon SJ, Ekstrand J, Ziegler EE. (2000). Fluoride intake and prevalence of dental fluorosis: trends in fluoride intake with special attention to infants. Journal of Public Health Dentistry 60: 131-9.

“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.”
SOURCE: 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.

“These findings suggest that in optimally fluoridated areas, the most prudent action by parents who wish to give their children formula, may be to use the ready-to-feed varieties. Alternately, these parents could dilute formula concentrate with bottled water instead of tap water. However, care would need to be exercised to be sure that the bottled water used contained a low fluoride concentration”
SOURCE: Pendrys DG, Katz RV. (1998). Risk factors for enamel fluorosis in optimally fluoridated children born after the US manufacturers’ decision to reduce the fluoride concentration of infant formula. American Journal of Epidemiology 148:967-74.

“All health professionals should understand the risks of preparing infant formulas with optimally fluoridated water and give precise recommendations to their patients. Additionally, this information should be emphasized in public health policies.”
SOURCE: Buzalaf M, et al. (2004). Risk of Fluorosis Associated With Infant Formulas Prepared With Bottled Water. Journal of Dentistry for Children 71:110-113.

“Breastfeeding of infants should be encouraged, both for the many documented, general health benefits and the relative protection against ingestion of excessive fluoride from high quantities of intake of fluoridated water used to reconstitute concentrated infant formula early in infancy.”
SOURCE: Levy SM, Kiritsy MC, Warren JJ. (1995). Sources of fluoride intake in children. Journal of Public Health Dentistry 55: 39-52.

“Use of powder concentrate would be recommended only for those with low-fluoride water.”
SOURCE: Levy SM, Kiritsy MC, Warren JJ. (1995). Sources of fluoride intake in children. Journal of Public Health Dentistry 55: 39-52.

“Our results suggest that the fluoride contribution of water used to reconstitute formulas increases risk of fluorosis and could be an area for intervention… Supporting long-term lactation could be an important strategy to decrease fluorosis risk of primary teeth and early developing permanent teeth.”
SOURCE: 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.

“Infant formulas should still be prepared using non-fluoridated water.”
SOURCE: Clarkson JJ, McLoughlin J. (2000). Role of fluoride in oral health promotion. International Dental Journal 50:119-28.

“The recommendation is that bottled or deionized water be used instead (of fluoridated water) to dilute the formula.”
SOURCE: Ekstrand J. (1989). Fluoride intake in early infancy. Journal of Nutrition 119(Suppl 12):1856-60.

“When formula concentrations need to be diluted, it is recommended parents use low fluoride bottled distilled water (labeled as “purified” or “distilled baby water”) or tap water with a reverse osmosis home water filtration system attached that removes most of the fluoride.”
SOURCE: Academy of General Dentistry. “Monitor Infant’s Fluoride Intake.” See article online

Breast-fed infants protected from fluoride:

“These findings show that plasma fluoride is poorly transferred to breast milk and infants thus receive almost no fluoride during breast feeding… The existence of a physiological plasma-milk barrier against fluoride suggests that the newborn is actively protected from this halogen. Hence the recommendation made in several countries to give breast-fed infants fluoride supplementation should be reconsidered.”
SOURCE: Ekstrand J, et al. (1981). No evidence of transfer of fluoride from plasma to breast milk. British Medical Journal 283: 761-2.

Formula-fed babies receive 100-200 times more fluoride than breast-fed:

“[I]nfant formulas reconstituted with higher fluoride water can provide 100 to 200 times more fluoride than breastmilk, or cows milk.”
SOURCE: Levy SM, Guha-Chowdhury N. (1999). Total fluoride intake and implications for dietary fluoride supplementation. Journal of Public Health Dentistry 59: 211-23.

“[I]n an area where the fluoride concentration is one part per million the daily fluoride dose in the newborn infant will be about 800-1000 ug/day (micrograms/day) when a milk substitute is used, whereas the fluoride dose for breast-fed children in the same area will not exceed 10 ug/day.”
SOURCE: Ekstrand J, et al. (1981). No evidence of transfer of fluoride from plasma to breast milk. British Medical Journal 283: 761-2.

High Fluoride Exposure During Infancy – A 20th Century Phenomena:

“Fluoride is now introduced at a much earlier stage of human development than ever before and consequently alters the normal fluoride-pharmacokinetics in infants. But can one dramatically increase the normal fluoride-intake to infants and get away with it?”
SOURCE: Luke J. (1997). The Effect of Fluoride on the Physiology of the Pineal Gland. Ph.D. Thesis. University of Surrey, Guildford. p. 176.

“[M]ore than 50 percent of infants are currently formula fed by 1 month of age, and these infants are likely to be continuously exposed to high intakes of fluoride for 9 or 10 months – a circumstance quite rare in the 1960s and early 1970s.”
SOURCE: Fomon SJ, Ekstrand J. (1999). Fluoride intake by infants. Journal of Public Health Dentistry 59(4):229-34.

“Overall, an average of 86.8% of the dose was retained by the infants, which is about 50% higher than would be expected for adults… There is a clear need for more information about the renal handling and general metabolism of fluoride in young children…”
SOURCE: Whitford GM. (1994). Intake and metabolism of fluoride. Advances in Dental Research 8:5-14.

“the uptake of fluoride into bone is greatest in infants and young children. Thus, infants who drink mainly powdered formula reconstituted with fluoridated water are likely to be a high-risk group for developing both skeletal fluorosis and hip fractures in old age.”
SOURCE: Diesendorf M, Diesendorf A. (1997). Suppression by medical journals of a warning about overdosing formula-fed infants with fluoride. Accountability in Research 5:225-237.

Formula made with fluoridated water a risk factor for dental fluorosis:

“[F]luoride intakes during each of the first 4 years were individually significantly related to fluorosis on maxillary central incisors, with the first year most important (P < 0.01), followed by the second (P < 0.01), third (P < 0.01), and fourth year (P = 0.03).”
SOURCE: Hong L, Levy SM, et al. (2006). Timing of fluoride intake in relation to development of fluorosis on maxillary central incisors. Community Dentistry and Oral Epidemiology 34(4):299-309.

“Our data suggest that the fluoride contribution of water used to reconstitute infant feedings is a major determinant of primary tooth fluorosis.”
SOURCE: 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.

“Our results suggest that breastfeeding infants may help to protect against fluorosis. This is consistent with other studies that suggest that consuming infant formula reconstituted with tap water increases the risk for dental fluorosis. Importantly, this study shows that the protective effect of breastfeeding is important not only in fluoridated communities but also in nonfluoridated areas. Parents should therefore be advised that they may be able to protect their children from dental fluorosis by breastfeeding their infant and by extending the duration for which they breastfeed.”
SOURCE: 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.

“The findings of this investigation suggest that nearly 10 percent of the enamel fluorosis cases in optimally fluoridated areas could be explained by having used infant formula in the form of a powdered concentrate during the first year.”
SOURCE: Pendrys DG. (2000). Risk of enamel fluorosis in nonfluoridated and optimally fluoridated populations: considerations for the dental professional. Journal of the American Dental Association 131(6):746-55.

“The findings indicate that early mineralising teeth (central incisors and first molars) are highly susceptible to dental fluorosis if exposed to fluoride from the first and – to a lesser extent – also from the 2nd year of life.”
SOURCE: Bardsen A, Bjorvatn K. (1998). Risk periods in the development of dental fluorosis. Clinical Oral Investigations 2:155-160.

“There was a strong association between mild-to-moderate fluorosis on later forming enamel surfaces and infant formula use in the form of powdered concentrate (OR=10.77, 95% CI 1.89-61.25).”
SOURCE: Pendrys DG, Katz RV. (1998). Risk factors for enamel fluorosis in optimally fluoridated children born after the US manufacturers’ decision to reduce the fluoride concentration of infant formula. American Journal of Epidemiology 148:967-74.

“[T]he odds ratio of fluorosis on enamel zones that began forming during the first year of life was 8.31 (95% CI = 1.84, 38.59) for children exposed since birth or during the first year of life relative to those exposed after 1 year of age. The odds that a child had a maxillary central incisor with fluorosis were 5.69 (95% CI = 1.34, 24.15) times higher if exposure occurred during the first year of life compared with exposure after 1 year of age. Only those exposed to the high-fluoride water during the first year of life developed fluorosis on the mandibular central incisors… The first year of life was a significant period for developing fluorosis on the mandibular and maxillary central incisors.”
SOURCE: Ismail AI, Messer JG. (1996). The risk of fluorosis in students exposed to a higher than optimal concentration of fluoride in well water. Journal of Public Health Dentistry 56:22-7.

“It appears that, at least under some circumstances, high intakes of fluoride during the early months of life may make the difference between developing or failing to develop dental fluorosis. A study conducted in Sweden of 12- and 13-year-old children who had lived since birth in a community with 1.2 ppm of fluoride in the drinking water demonstrated that dental fluorosis was less common in those who had been breast-fed during the first 4 months of life than in those who had been fed powdered formulas reconstituted with tap water (Forsman, 1977). A somewhat similar study in the United States demonstrated that among 7- to 13-year-old children (most of them living in a community with fluoride concentration of the drinking water 1 mg/L), the prevalence of mild enamel fluorosis was significantly greater in those who had been fed concentrated liquid formula diluted with tap water during the first 3 months of life than in those who had been breast-fed during this time (Walton and Messer, 1981). It seems reasonable to conclude that the lower prevalence of fluorosis of the permanent teeth of individuals who were breast-fed during the early months of life is related to the low fluoride concentrations of human milk – concentrations less than 7 ug/L regardless of the concentration of fluoride in the women’s drinking water.”
SOURCE: Ekstrand J, et al. (1994). Absorption and retention of dietary and supplemental fluoride by infants. Advances in Dental Research 8:175-80.

“Like bones, a child’s teeth are alive and growing. Flourosis is the result of fluoride rearranging the crystalline structure of a tooth’s enamel as it is still growing. It is evidence of fluoride’s potency and ability to cause physiologic changes within the body, and raises concerns about similar damage that may be occurring in the bones.”
SOURCE: Environmental Working Group, “National Academy Calls for Lowering Fluoride Limits in Tap Water”, March 22, 2006.

“A linear correlation between the Dean index of dental fluorosis and the frequency of bone fractures was observed among both children and adults.”
SOURCE: Alarcon-Herrera MT, et al. (2001). Well Water Fluoride, Dental fluorosis, Bone Fractures in the Guadiana Valley of Mexico. Fluoride 34(2): 139-149.

“it is illogical to assume that tooth enamel is the only tissue affected by low daily doses of fluoride ingestion.”
SOURCE: Dr. Hardy Limeback, Head of Preventive Dentistry, University of Toronto. (2000). Why I am now Officially Opposed to Adding Fluoride to Drinking Water.

“The safety of the use of fluorides ultimately rests on the assumption that the developing enamel organ is most sensitive to the toxic effects of fluoride. The results from this study suggest that the pinealocytes may be as susceptible to fluoride as the developing enamel organ.”
SOURCE: Luke J. (1997). The Effect of Fluoride on the Physiology of the Pineal Gland. Ph.D. Thesis. University of Surrey, Guildford. p. 176

“It seems prudent at present to assume that the ameloblasts are not the only cells in the body whose function may be disturbed by the physiological concentrations of fluoride which result from drinking water containing 1 ppm.”
SOURCE: Groth, E. (1973), Two Issues of Science and Public Policy: Air Pollution Control in the San Francisco Bay Area, and Fluoridation of Community Water Supplies. Ph.D. Dissertation, Department of Biological Sciences, Stanford University, May 1973.

See these additional articles on infants and fluoridation:

The Centers for Disease Control as of 10/3/10 states:

Until now, most researchers concluded that fluoride intake during a child’s first 10 to 12 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.”[3]

The CDC fails to mention which one of the many studies raising warnings for infants the CDC finally actually read and became concerned.

“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. . . .Ready to feed (no-mix) infant formula typically has little fluoride and may be preferred for use at least some of the time.[4]

“[M]any infants have a fluoride intake just from tap water that exceeds EPA’s reference dose for fluoride.” http://www.iaomt.org/articles/files/files282/Theissen_MET_presentation[1].pdf

Our recommendation for rule change is for water containing a concentration of 0.01 ppm fluoride as measured when the mother is on fluoridated water at 1ppm.  0.01 ppm is actually higher than the mean concentration of fluoride in mother’s milk and may not be protective.  The Board has every right to suggest 0.01 ppm fluoride is excessive and warnings should be made for all water above zero, the concentration of the majority of mother’s milk when mothers are drinking nonfluoridated water.  Those promoting fluoridation should not object to a concentration of 0.01 ppm for infants, which is higher than the mean level of fluoride measured in mother’s milk, colostrum, cow’s milk or no-mix infant formula.

IV. PETITION FOR WAC CHANGE: WAC 246-290-460

WAC 246-290-460 should be changed to add the following wording:

Where fluoride concentrations in group A water systems average above 0.01 ppm or if the system is without the ability to measure low concentrations of fluoride, water suppliers shall include the following notice with each customer’s water bill, “The Washington State Board of Health recommends mother’s milk for infants. This water provides a higher concentration of fluoride for infants than mother’s milk.  Use non-fluoridated water for infant drinking and infant formula preparation.”

Sincerely yours,

Bill Osmunson DDS, MPH
President, Washington Action for Safe Water
1418 – 112th Ave NE 200
Bellevue, WA 98004
425.455.2424


[1] http://aappolicy.aappublications.org/cgi/content/full/pediatrics;115/2/496 Accessed 9/28/10  The AAP policy statement is rich with support for this petition.

[2] NRC 2006 page 27.

[3] http://www.cdc.gov/fluoridation/safety/infant_formula.htm Accessed 10/3/10

[4] http://www.cdc.gov/fluoridation/safety/infant_formula.htm#1 Accessed 10/3/10

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