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0PEDIATRICS (ISSN 0031 4005). Copyright © 1986 by theAmerican Academy of Pediatrics.

Committee on Nutrition

758 PEDIATRICS Vol. 77 No. 5 May 1986

Fluoride Supplementation

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Since publication of the previous statement on

fluoride, which was issued by the Committee onNutrition in 1979,’ further information has

emerged regarding the mode of action of fluoride inpreventing caries.27 There has also been growing

recognition of the narrow therapeutic range of flu-oride and the danger of excess fluoride ingestionwhich results in dental mottling (fluorosis).8 This

statement reviews some of the newer information

about fluoride and offers guidance on the optimal

use of fluoride supplements.

MODES OF ACTION

Fluoride has both systemic and topical actions

that are of importance in dental health. Systemi-

cally, fluoride acts on teeth prior to their eruptionby being built into the crystal structure of theenamel and making it resistant to decay. In addi-

tion, fluoride limits enamel demineralization andencourages its remineralization into a stable struc-ture.5 The result is to reduce the likelihood of toothdecay.24 The mineralization of primary teeth be-gins in utero, and this has led to the suggestion that

fluoride supplements be given in pregnancy. How-ever, there is little evidence of the effectiveness offluoride supplementation in pregnancy.7’9 The per-manent first molars start mineralization of their

crowns shortly after birth.’#{176}Mineralization of per-manent teeth continues up to 6 years of age. Thus,the systemic effects of fluoride are exerted during

this period.’0 Conversely, excess fluoride ingestion

during this period can cause fluorosis.” The opti-mal systemic fluoride dosage to prevent caries ap-pears to be 0.05 to 0.07 mg/kg/d.’2 The narrownessof the therapeutic range is emphasized by the fact

that mild fluorosis has been seen with oral intakesgreater than 0.1 mg/kg/d.’3 Thus, it is important toexamine carefully the data on the age at whichfluoride supplementation is started and its relation-ship to caries prevention. At present, there is no

evidence that starting fluoride supplementation

earlier than 1 year of age results in any furthercaries prevention in permanent teeth.’#{176}On theother hand, starting fluoride supplementation prior

to 1 year of age does provide additional protectionfor deciduous teeth.’#{176}This becomes a pediatric issuebecause most dentition occurs at such an early age.

Preeruptive excess fluoride intake affects dental

enamel mineralization and results in mottling ofthe teeth (fluorosis). For the permanent teeth, the

most critical period of vulnerability to excess fluo-ride occurs at approximately 2 years of age. Becauseenamel formation is virtually complete by age 5 to

6 years, systemic effects of fluoride are, for the mostpart, accomplished by this time. Topical effects,however, remain important.

Fluoride acts topically (ie, directly on erupted

teeth) by promoting remineralization and, in addi-tion, possibly through antibacterial effects.2 These

topical effects appear to be significant mechanisms

for the prevention of tooth decay. It is likely thatregular exposure of the tooth surface to low dosesof fluoride may be more critical to preventing caries

than the amount of “systemic” fluoride ingestedduring tooth formation.’4 The amounts of fluorideingested from eating tooth paste can be an impor-tant source because tooth paste contains 1 mg of

fluoride per gram. Precautions should be observed.The relative roles of topical v systemic effects of

fluoride are still being debated.’5 It is clear, how-ever, that the presence of fluoride during the periodof tooth formation alone will not prevent tooth

decay as effectively as the combination of systemicfluoride plus regular topical application of fluoride

to erupted teeth. To be effective, topically appliedfluoride must be used regularly,6”4 as the high levelof fluoride found in enamel shortly after topicalapplication is maintained for less than 1 month.

METHODS OF PROVIDING FLUORIDE

The best method of providing fluoride is by add-

ing fluoride to the local water supply. When fluorideis added to water, it acts as a regular source of

topical fluoride to the teeth while it is also availablesystemically. The decision to fluoridate water to

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AMERICAN ACADEMY OF PEDIATRICS 759

the proper level is made locally, and the practice offluoridation varies considerably across the country.

Other methods of providing fluoride include flu-

oride-containing drops, tablets, mouthwashes, gels,� 0 and dentifrices. Several available preparations con-

� tam both fluoride and vitamins. Their combined� use is necessary only in infants who require supple-� mental vitamins. Parents should be aware of the� dangers of fluoride overdose and should be cau-

� tioned not to exceed the prescribed amount. Al-� though effective, the success of these alternative� methods is heavily dependent upon the motivation� of the parents to ensure that the preparations are� taken daily in a proper dose. Studies have shown

� that parents are frequently unable to devote their� attention to fluoride administration, and as a corn-

� rnunity measure, none of these methods is as effec-� tive as fluoridation of the water supply.’6’17

� On the other hand, for children living in areas� without water fluoridation, toothpastes containing� fluoride are a particularly important source of flu-

� oride. Virtually unknown 25 years ago, these prod-� ucts now command more than 90% of the market� and may account for the observed decline in dental

� caries prevalence in populations not otherwise re-

� ceiving fluoride supplements.’8”9

� USE OF FLUORIDE FOR YOUNG INFANTS

In the 1979 statement, the Committee discussed

0 the literature for and against introducing fluoridesupplementation at 2 weeks of life v delaying sup-plementation until 6 months ofage.’ The increasing

realization of the important role that topical fluo-ride plays in the prevention of dental caries’4 andthe realization that early systemic fluoride inges-

tion will not prevent dental caries in permanentteeth, unless there is continued exposure to fluo-ride, has led to a reexamination of the use of fluo-ride before 6 months of age. An additional concernregarding the use of fluoride supplements prior to6 months is the possible effect of transiently high

levels of fluoride, which might occur if infants weregiven fluoride supplements on a once-a-day ba-

sis.5’7”4”8 In experimental studies, peaking of

plasma fluoride levels in animals has resulted influorosis.’320’2’ However, present data suggest thatthe current fluoride dosage’ would not be sufficient

to cause fluorosis. It is also important to realizethat, from the time of birth, fluoride is incorporatedinto the deciduous teeth and reduces caries in these

teeth.’#{176}The issue of fluorosis is further complicatedby the variation in infant-feeding patterns occur-ring during this time.

Infants Who Consume Only Milk

0 The amount of fluoride consumed by the infantfed only milk is difficult to determine. Human milk

contains 16 ± 5 sg of fluoride per liter,22 a smallamount. The amount of fluoride absorbed is un-known but is probably equivalent to absorption

from other milks (65%)23 The amount of fluoridein human milk is related only slightly to the amount

of fluoride in the mother’s diet.24 There may beother elements, such as strontium, acting togetherwith fluoride to reduce caries.25 It is of interest to

note that, in areas that use water fluoridation,infants fed only human milk and not receiving

fluoride supplements had caries rates comparableto those of formula-fed infants.26 Therefore, it maynot be necessary to give fluoride supplements tobreast-fed infants who are living in an area wherethe water is adequately fluoridated. The pediatri-cian must determine whether there is a need for

fluoride supplementation, ie, for infants receivingbreast milk only (no water, juice, or solid foods).

The manufacturers of infant formula now maketheir products with defluoridated water so that thefluoride content is <0.3 ppm. This simplifies thecalculation of an infant’s total intake of fluoride.

Infants Who Consume Fluoride and Solid Foods

Although most infant foods have a low level offluoride, some contain appreciable amounts. Thefluoride intake of6-month-old infants in the United

States has been estimated to vary from 0.207 to0.541 mg/d (0.03 to 0.07 mg/kg/d).27 Although largeamounts of fluoride have been obtained from for-

mulas and water, dry cereals and vegetable productshave also contributed significant amounts. Data on

fluoride intake in Canadian infants show that in-take varies considerabl?8 but is similar to that ofinfants in the United States.

Solid foods are commonly added to the diet after

4 months of age, and by 6 months of age manyinfants are consuming a varied diet. Although largeamounts of solid foods are not likely to be consumed

at any one sitting, and thus peak blood levels areunlikely to be a problem, the total amount of fluo-ride added to the diet may be appreciable. However,the intake of solid foods reduces fluoride absorption

to about 60% of intake.29’30 Total fluoride intakeswith the supplementation doses suggested below

have been calculated to not exceed the optimal

dosage range of 0.05 to 0.07 mg/kg/d.

FLUORIDE SUPPLEMENTATION

The fluoride content of the water supply varieslocally. Thus, any dosage regimen must take into

consideration the local conditions. In addition, thefluoride content of processed foods and carbonatedbeverages must be taken into account in consider-ing a child’s total intake of fluoride.8 At present,data on the fluoride content of processed foods and

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TABLE. Fluoride Supplementation Schedule for Infantsand Children

REFERENCES

1. American Academy of Pediatrics, Committee on Nutrition:Fluoride supplementation: Revised dosage schedule. Pedi-atrics 1979;63:150-152

2. Thylstrup A, Fejerskov 0, Brunn C: Enamel changes anddental caries in 7-year-old children given fluoride tabletsfrom shortly after birth. Caries Res 1979;13:265-276

3. Aasenden R, Peebles TC: Effects of fluoride supplements-tion from birth on human deciduous and permanent teeth.Arch Oral Biol 1974;19:321-326

4. Adair SM, Wei SHY: Supplemental fluoride recommenda-tions for infants based on dietary fluoride intake. Caries Res1978;12:76-82

5. Holloway PJ, Levine RS: The value of self-applied fluoridesat home. Intl Dent J 1981;31:232-239

6. Mellberg JR, Nicholson CR, Rips LW, et al: Fluoride dep-osition in human enamel in vivo from professionally appliedfluoride prophylaxis paste. J Dent Res 1976;55:976-979

760 FLUORIDE SUPPLEMENTATION

beverages are insufficient to allow adjustment ofdosage schedules for children in areas in which

supplemental fluoride is recommended. Dosage reg-imens are based on the age of the child, as well asthe fluoride content in the local water supply, with

the intention of providing sufficient fluoride forcaries prevention, while at the same time avoiding

an excess that may cause dental mottling. Ideally,

the fluoride content of the local water supply in allcommunities should be adjusted to a level between0.7 and 1.0 ppm. In communities that have insuf-

ficient fluoride in the local water supply, fluoridesupplementation should be used according to the

dosage schedule shown in the Table. This dosageschedule is identical with that presented in the

Committee statement of 1979.’ The fluoride can be

provided in the form of drops or tablets.

There is some concern that children 2 to 4 yearsof age who are using fluoride-containing dentifrices

or mouthwashes may swallow them instead of spit-

ting them out.’4”8’3�32 This may well lead to exces-sive fluoride intake (up to 1 mg of fluoride per dayfrom the dentifrices alone) and could result in mild

cases of fluorosis. For these reasons, the Committeerecommends that, if a fluoride-containing dentifriceis used by a toddler, only a very small amount of

toothpaste should be placed on the brush. In addi-tion, parents should be advised to teach their chil-

dren not to swallow the toothpaste.

Because many children do not see a dentist forthe first few years of life, the pediatrician shouldassume responsibility for overseeing proper fluorideusage as follows: (1) determine the fluoride concen-tration of the local water supply for all of yourpatients, (2) know and use the fluoride supplemen-

tation schedule appropriately, and (3) counsel par-ents with regard to the proper use of fluoride-containing dentifrices (toothpastes and gels).

SUMMARY

This statement reviews the rationale for the use

of fluoride supplements for infants and children.The concept of fluoridation of water supplies as aneffective and cost-beneficial method of reducing

Age(yr)

FluorideW

Concentration in Localater Supply (ppm)

<0.3 0.3-0.7 >0.7

0-2 0.25 0 02-3 0.50 0.25 0

3-16 1.00 0.50 0* Values are milligrams of fluoride supplement per day.

Supplementation should begin in the first 2 weeks afterbirth.

caries prevalence in the general population isstrongly supported. In the absence of an adequatelyfluoridated water supply, fluoride supplements

should be given to all children. This should beginat about 2 weeks of age; the dosage will depend onthe concentration of fluoride in the local water

supply. Fluoride-containing dentifrices are an im-portant source of topical fluoride, but it is essential

that parents be aware of the danger of excessivefluoride intake and that they teach their childrento avoid swallowing toothpaste.

COMMITTEE ON NUTRITION, 1985-1986Laurence Finberg, MD, ChairmanHarry S. Dweck, MDNorman Kretchmer, MD

Frederick Holmes, MDAlvin M. Mauer, MD

John W. Reynolds, MDRobert W. Suskind, MD

Liaison RepresentativesJohn D. Benson, PhD

Stanley G. Miguel, PhDGeorge A. Purvis, PhDRichard C. Theuer, PhDRudolph M. Tomarelli, PhD

Alice Smith, RDA. Harold Lubin, MD

Ann Prendergast, RD, MPHMargaret Cheney, PhD

Reginald Sauve, MDMary Serdula, MDJoginder Chopra, MDThorsten J. Fjellstedt, PhDStephen Joseph, MDMs. Patricia Daniels, RD, MS

Section LiaisonStanley Hellerstein, MD

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AMERICAN ACADEMY OF PEDIATRICS 761

7. Stookey GK: Perspective on the use of prenatal fluoride: Areactor’s comments. J Dent Child 1981;48:126-127

8. Powell JA, Norbert LD, Hargreaves JA: Fluorosis and dentalcaries in children receiving fluoride supplementation. J Dent

0 Res 1983;62:2039. Driscoll WS: A review of clinical research on the use of

prenatal fluoride administration for prevention of dentalcaries. J Dent Child 1981;48:109-117

10. Marthaler TM: Fluoride supplements for systemic effects incaries prevention, in Johansen E, Taves DR, Olson TO(eds): Continuing Evaluation on the Use of Fluorides, sym-posium 11. Boulder, CO, AAAS Selected Symposium West-view Press, 1979, pp 33-59

1 1. Moller IJ: Fluorides and dental fluorosis. mt Dent J1982;32:135-147

12. Forrester DJ, Schultz EM (ads): International Workshop onFluorides and Dental Caries Reductions. Baltimore, Univer-sity of Maryland, 1974

13. Forsman B: Early supply of fluoride and enamel: Fluorosis.Scand J Dent Res 1977;85:22-30

14. Dowell TB, Joyston-Bechal 5: Fluoride supplements-Agerelated dosages. Br Dent J 1981;150:273-275

15. Bruun C, Poulsen 5, Costergaard V, et al: Preemptive ac-quisition of fluoride by surface enamel of permanent teethafter daily use of F supplements. Caries Res 1983;17:89-91

16. Murray JJ: Fluoride supplements-Alternatives to waterfluoridation. J R Soc Health 1977;97:48-51

17. Gray AS, Gunther DM: Supplemental fluorides: A commu-nity health centre project in preventive dentistry. Can JPublic Health 1976;67:55-58

18. Ekstrand J, Koch G, Petersson LG: Plasma fluoride concen-trations in pre-school children after ingestion of fluoridetablets and toothpaste. Caries Res 1983;17:379-384

19. Hargreaves JA, Thompson GW, Wagg BJ: Changes in cariesprevalence in Isle of Lewis children 1971 and 1981. CariesRes 1983;17:554-559

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20. Kruger BJ: The effect of different levels of fluoride on theultrastructure of ameloblasts in the rat. Arch Oral Biol1970;15:109-114

21. Suttie JW, Carlson JR, Faltin EC: The effects of alternatingperiods of high- and low-fluoride ingestion on dairy cattle.J Dairy Sci 1972;55:790-804

22. Lonnerdahl B: Composition of human milk, in PediatricNutrition Handbook, ed 2. Elk Grove Village, IL, AmericanAcademy of Pediatrics, 1985

23. Spak CJ, Ekstrand J, Zylberstein D: Bioavailability of flu-oride added to baby formula and milk. Caries Res1982;16:249-256

24. Spak CJ, Hardell LI, de Chateau P: Fluoride in human milk.Acta Paediatr Scand 1983;72:699-701

25. Curzon MEJ: Combined effect oftrace elements and fluorideon caries: Changes over ten years in northwest Ohio (USA).J Dent Res 1983;62:96-99

26. Walton JL, Messer LB: Dental caries and fluorosis in breast-fed and bottle-fed children. Caries Res 1981;15:124-137

27. Ophaug RH, Singer L, Harland BF: Estimated fluorideintake of 6-month-old infants in four dietary regions of theUnited States. Am J Clin Nutr 1980;33:324-327

28. Dabeka RW, McKenzie AD, Conacher HBS, et al: Deter-mination of fluoride in Canadian infant foods and calcula-tion of fluoride intakes by infants. Can J Public Health1982;73:188-191

29. Welling PG: Influence of food and diet on gastrointestinaldrug absorption: a review. J Pharmacokinet Biopharm1977;5:291-334

30. Ekstrand J, Ehrnebo M: Influence of milk products onfluoride bioavailability in man. Eur J Clin Pharmacol1979;16:211-215

31. Ericsson Y, Wei SHY: Fluoride supply and effects in infantsand young children. Pediatr Dent 1979;1:44-54

32. Dowell TB: The use of toothpaste in infancy. Br Dent J1981;150:247-249

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