1. Fluoridated water and concentrated formula.

2. Commercial baby water and powdered formula.

3. OptiDose® dropper with supplements, for breast-fed and other ~zero fluoride methods of feeding.

(See below for discussion, see dosing recommendations for specifics.)

Until now there has always been a tradeoff between getting too little fluoride (= tooth decay) and too much fluoride (= discolored teeth). In the last few decades many children have reached the goal of zero cavities, AND very nice-looking teeth. Many others came close - only a few cavities and/or a few small white spots.

It is amazing that we have done as well as we have. Some water has lots of fluoride, and some water has almost none. Some children are fed powdered formulas, which use lots of water, and others are breast fed and get none. Supplements were no better. They have come in one-dose-fits-all products, even though children vary greatly in size. (In the first products in 1962, the same doses were used all the way from birth to age 3 - when most kids grow about 500%.)

There is also the problem of just not knowing which dose is ideal. It takes about 10 years to see the result of how much fluoride a child is given. And none of the trials used a specific dose for the entire time a child's teeth are forming.

I would like to think that we now know what the perfect doses should be. We don't really, but a very good guess is about .033 mg F / kg. (There is more discussion on how that guess was made elsewhere.) So now it should be just a matter of working with various feeding methods and various levels of fluoride in the water. Here are 3 "easy" ways to get "perfect" doses of fluoride in infancy. (I'll also cover some trickier ones that many of your patients will not be able to follow.)

Doses in proportion to calories of food (various ways of mixing the fluoride in the formula).

It is common to get warnings about "fluoridated water plus powdered formula". This has been shown to give a dose that is over the threshold of fluorosis (generally accepted to be .1 mgF/kg). For example, Ekstrand showed a detailed balance study on 5 infants being fed powdered formula made with fluoridated water. For the youngest child (8 weeks) the intake was the highest at .19 mg F / kg. For the oldest child (17 weeks) the intake was the lowest at .10 mg F / kg. (Pediatric Research 1994 35(2):157). This amount of fluoride in this method of feeding has been shown to cause about 20% of the kids a mild grade of fluorosis. (Forsman B. Early supply of fluoride and enamel fluorosis. Scandinavian Journal of Dental Research 1977;85:22-30. One area in her study had water with 1.2 PPM F. If the children were fed with powdered formula before the age of 3 months, 36 out of 155 (23%) of them had mild fluorosis, versus 3 out of 41 (7%) if the formula started after 3 months (and versus 0% if no powdered formula). However, in these cases "this mild degree of fluorosis presented absolutely no aesthetic problem".)

While the above method - fluoridated water with powdered formula - may cause some minor spotting in very young children, there are two good methods that are theoretically perfect:

Fluoridated water is about two times too much for use with powdered formula. But fluoridated water with CONCENTRATED formula (uses half as much water) is perfect method #1. Fluoridated water is available out of the tap for about 60% of the country, and in 5-gal home delivery in most of the rest (see link below).  Most stores carry small bottles of Dannon Fluoride to Go®. Some stores carry some Nestle brands of water with fluoride, like Deer Park® fluoridated water.

Next, if you're going to use powdered formula, there are commercial waters made just for baby. (NURSERY® Purified Water with added Fluoride  and Beech-Nut® Bottled Water with added Fluoride are two national brands. In the midwest Hy-Vee has Mother's Choice Infant Water with fluoride.) These have about half the fluoride of regular fluoridated water, and are perfect for use with powdered formula (perfect method #2).

(Well, some have .5 ppm, which to me is perfect for powdered formula, and some have a wee bit lower or higher. Like NURSERY® is .7 ppm, which is to me is still 99% perfect. No one has tested all these permutations, so it is somewhat a guess anyway. There are also some other store brands of infant / baby water, with and without fluoride. I haven’t checked on all brands, and would appreciate any info.)

This method is great for us dads. All we need for a day's excursion with the kid is a bunch of diapers, a jug of NURSERY® water, and a few bottles with the powder already in the little bags. (Assuming you have the baby used to formula being room temperature.)

To me these waters are the best new thing for babies’ teeth to come along since Poly-Vi-Flor® back in 1962. The water companies cannot talk too much about their health benefits or safety features (there have not been clinical trials to back up any claims), but they are intuitively about the safest way to get fluoride to a small child. Since the “strongest” way they could be used is with powdered formula, and they are perfect for that, by definition they are safe for virtually any other infant use (regular drinking, juice mixing, cooking, etc.) which use far far less water / fluoride. About the only way you could overdose is using them with fluoride supplements. Even then you would be only at about the other slightly-too-much doses anyway (ie, about like powdered formula with fluoridated water, or the old 1962-74 doses). You could underdose, of course, but that happens with lots of babies anyway. A little is better than dead zero.

You can also have very competent parents mix their own fluoridated baby water. To make the half-strength type for powdered formula, just drop in two 1 mgF tablets (2.2 mg NaF) into a gallon of water. (Regular fluoridated water is one tab per quart or liter.) Or, if parents have fluoridated water they can mix it 50-50 with unfluoridated bottled water to make the half-strength baby water.

Common risks with food methods: Probably switches, like from concentrated formula to powdered. But since it takes a few months' worth of "mistakes" to show, this risk is probably minimal as long as the patient is seeing the pediatrician fairly often. Parents could also switch down, like from fluoridated water to plain water, or quit using formula. But once again the risk is minor - maybe a few extra cavities (this risk is not well-studied).

Certainly lots of infants are on both extremes all the time anyway. For example, in fluoridated areas lots of kids use powdered formula and lots are breast fed. The former we covered above. The same study showed that all of the breast fed ones were in negative fluoride balance. This can last 6 months or more. So our methods to more or less split the difference between common extremes is a reasonable option.

Proof of the method: Mixing fluoride with food lacks the clinical trials of supplements, but fluoridated water studies give it plenty of credence. The fact that at twice this intake fluorosis starts to show up certainly implies that we are in the right range. The only evidence I know of that says this method / dose would not be enough is from a balance study. Based on fluoride retained, giving small doses in the food may be only about one fourth of the same total dose in a daily supplement. I'll give you that reference and the relevant quote from it, but I still think this method and dose with food is enough or very close. (Ekstrand J, Ziegler EE, Nelson S E, Fomon S J. Absorption and retention of dietary and supplemental fluoride by infants. Advances in Dental Research Jul 1994; 8(2):175-80. In Regimen A, small amounts of fluoride were obtained in the diet in frequent doses throughout the day; in Regimen B, a fluoride supplement (.025 mg) was given each day with a feeding; Regimen C was similar to regimen B except that the fluoride supplement was given 1 hour before a feeding. ... the respective retentions were 12.5, 47.1, and 52.3% of intake.)

Doses in proportion to body weight (various ways of using fluoride supplements).

The interim AAP schedule (Pediatrics May 1995) does not give infants fluoride from birth to age 6 months. Historically, this age group originally got .5 mg (which was clearly too much) (Aasenden R, Peebles TC. Archives Oral Biology 1974; 19:321 and 1978; 23:111.). In 1979 the doses were lowered to .25 mg. I haven't seen any great data on this dose, but there are plenty of teenagers with very mild fluorosis. Now, by shifting to body weight doses, in effect we'll cut the dose in half again and keep it even. (Elsewhere we'll discuss step doses, etc.)

Using fluoride supplements is more or less the only choice for breast feeding and RTU (ready-to-use) formula feeding. This method can also be used with other types of formula feeding, as long as the formula is not mixed with fluoridated water.

The perfect method (#3) we suggest is to use the OptiDose® dropper with supplements. In this way the dose is exactly by body weight. We assume most parents will be able to use this one successfully. It is probably the easiest way to be fully compliant. Since most parents do not have a good scale, it is probably a good idea to give the parents the body weight written down as often as possible. The Rx instructions could also have the weight right on the label, such as: "Fill to 10 pounds body weight and give orally once per day".

A method that could do the same thing without our dropper is to just eyeball the doses. If you look at our dropper, you'll see a full dropper (1 ml) is 16 pounds, and a half full dropper is 8 pounds. From that you can construct fairly simple directions to go with a plain 1 ml dropper. The simplest would be to start at birth with a half full dropper and by age 6 months be up to a full dropper.

In either method of dosing supplements (by weight or by eyeball), there is the issue of the infant rejecting the taste of the vitamins. The best method I know of is originally from our family pediatrician (Dr. Sylvia Pager, Honolulu). Here is the language I use in our instructions to the parents: "Most pediatricians say the best way to get an infant to take vitamins is to do it at the morning feeding when the baby is the hungriest. Get all set to feed, then give the vitamins first in one quick sploosh, then immediately start feeding. The reaction you want is "What was that? Ah, here we go with the good stuff."

Conclusion: It is not that big of a deal if you don't go out of your way to get the dose of fluoride just right. Most kids get some here and there and things work out well enough. The worst that will happen if you get too little is a few cavities, and the worst that will happen if you get too much is a few little white spots. If you get it perfect during the whole time teeth are forming, each and every tooth will be a gorgeous white color, have glossy enamel, and not a trace of decay. I think most parents would appreciate a chance to strive for this goal. However, I don't think we should act like it will be easy. The time teeth are forming spans from early in pregnancy until about the first grade. It is a long time to be a perfectionist.