1. Oral Health Services Research Centre, UCC Fluoride Levels in Powdered Infant Formula Reconstituted with Fluoridated Water

2. Oral Health Services Research Centre, UCC ESRI Study - 1999 37% of Irish mothers breastfeed

3. Oral Health Services Research Centre, UCC Background Euro Growth Study Conducted at 22 European Centres from 1992-1996 Lowest level of breast feeding was recorded in Ireland

4. Oral Health Services Research Centre, UCC Although breast is best Most babies in Ireland are bottle fed

5. Oral Health Services Research Centre, UCC Background Infants fed with formula reconstituted with fluoridated water ingest higher levels of fluoride than breast fed infants How much Fluoride ion is ingested in reconstituted formula?

6. Oral Health Services Research Centre, UCC Safety of tap water for reconstituting baby formula

7. Oral Health Services Research Centre, UCC Fluoride Ingestion Intake of fluoride associated with acute toxic effects is considered to be 5 mg fluoride (F(-))/kg body weight A newborn baby weighing 3kg would have to drink 15 litres of water fluoridated at 1ppm to ingest this level of fluoride Data on free fluoride levels in formula reconstituted with fluoridated water was needed to estimate fluoride ingestion by infants (only free fluoride can be absorbed in the GIT)

8. Oral Health Services Research Centre, UCC There is an anecdotal evidence to suggest that some mothers make batch formula for use in the following 24 hours Fluoride forms insoluble precipitates with ionic calcium and complexes with other divalent and trivalent cations. Free Fluoride

9. Oral Health Services Research Centre, UCC Aims To determine whether ionic (free) fluoride in infant formula reconstituted with fluoridated water is the same as that in water To quantify the changes in free fluoride concentration in infant formula reconstituted with fluoridated water changes over a 24 hour period To investigate the association between formula calcium levels and free fluoride concentration in infant formula reconstituted with fluoridated water

10. Oral Health Services Research Centre, UCC Methods Six formula feeds were analysed: 1)Milupa Milumil 2)Milupa Aptamil First 3)Cow & Gate Omneo Comfort 4)SMA Gold 5)Milupa Forward (6 months +) 6)SMA Progress (6 months +) Manufacturers instructions were followed when mixing powder and water

11. Oral Health Services Research Centre, UCC Methods Repeated analysis of the ionic (free) fluoride concentrations of the reconstituted formula –Immediately after reconstitution –At hourly intervals post - reconstitution up to 6 hours –24 hours post- reconstitution Fluoride ion-specific electrode and reference electrode (Orion Models 94- 09, 90-01)

12. Oral Health Services Research Centre, UCC Results In the case of the four formula recommended for use from birth the mean reductions in the amount of free fluoride relative to fluoridated water were: 15.9% (Milupa Milumil), 5.8% (Milupa Aptamil), 9.5% (SMA Gold) 9% (Cow & Gate Omneo Comfort )

13. Oral Health Services Research Centre, UCC Results Mean reductions in free fluoride in the two formula recommended for use from 6 months onwards were: 14.4% (Milupa Forward) 37.9% (SMA Progress) For all six formulae there was a significant drop in the level of free fluoride in the tap water once the formula was added

14. Oral Health Services Research Centre, UCC Free Fluoride concentration over time by formula

15. Oral Health Services Research Centre, UCC Results Free Fluoride in formula was lower than water (p < 0.0001) There was an overall difference in Fluoride concentration among the six formulae (p < 0.0001) Fluoride concentration varied over time (p < 0.0001) The differences over time were similar for the six formulae (p =0.4666)

16. Oral Health Services Research Centre, UCC Results Concentration (mg/100ml) Element Milupa Aptamil Milupa Milumil C&G Omneo SMA Gold SMA Progress Milupa Forward Calcium 60 76 53 46 90 87 %dec F 5.8 15.9 9 9.5 37.9 14.4

17. Oral Health Services Research Centre, UCC Conclusions There is a wide variation in the levels of ionic (free) fluoride in the different powdered infant formula reconstituted with tap water Free fluoride is associated with calcium content Fluoridated water is safe for use in babyfood, fluoride intake is well within the safe level Some mineral waters have a high salt content which is dangerous for babies

18. Oral Health Services Research Centre, UCC Estimate of the average daily fluoride intake of infants residing in fluoridated areas, during the first 4 months of life Anderson et al The mean acute exposure of infants to fluoride in areas served by fluoridated water supplies was estimated to be between 0.11 and 0.14 mg/kg body weight per day These predicted intakes were well below the intake of fluoride associated with acute toxic effects (5 mg fluoride (F(-))/kg body weight) Dental fluorosis may be considered to be the only risk at these low doses