Dietary Sources of Fluoride for Infants and Children in Hong Kong Faiez N
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PEDIATRIC DENTISTRY/Copyright © 1988 by The American Academy of Pediatric Dentistry Volume 10, Number 1 Dietary sources of fluoride for infants and children in Hong Kong Faiez N. Hattab, BDS, PhDStephen H.Y. Wei, DDS, MS, MDS Abstract tary patterns in recent years and the current multiple The purposeof this study was to investigate the dietary sources of F ingestion, it is important to assess the daily sources of fluoride (F) for infants and children residing total F intake of different age groups of children residing HongKong. Analyses were made on commercially available in fluoridated and F-deficient communities. There is foods and beveragesas well as hospital infant diets. Fooditems concurrent evidence to indicate that there is an increase from different countries of origin also were analyzedin order in the occurrence of mild enamel fluorosis amongchil- to assess the variation in sources of F for children living in dren in fluoridated and some nonfluoridated communi- different communities. ties? In this context, a special issue of the Journalof Dental The findings indicate that whole cow’s milk contained as Research (1987) was devoted to measures in optimizing low as 0.01 ppmF. The F content in powderedinfant formulas the safety and efficacy of F therapy. (undiluted) varied from 0.06 to 1.08 ppm, with an average Analysis of the F content in individual foods is the 0.39 ppm. Hospital infant foods were found to rangefrom 0.27 first step in monitoring the total F intake of infants and to 0.93 ppmF with an average of 0.59 ppm. Relatively high children. The concentrations of F and other trace ele- sources of F were found in soups prepared from seafoods. ments in tea infusions and their contribution to the daily Mineral~springwater, in general, containedlow F concentra- F intake recently have been reported (Wei et al. 1987). tions of 0.01-0.10 ppmand therefore does not significantly Beverages and milk formulas are the main sources of F contribute to F intake if usedin reconstitutionof milk powder- when they are processed or prepared with fluoridated or concentrated milk formulas. The average F contents in water. 4 The consumption of commercially prepared soft cannedsoft drinks and fruit-flavored drinks were 0.42 and drinks and other beverages is increasing in Hong Kong 0.56 ppm, respectively, while for prepackagedfruit juices, as well as in most parts of the world. For example, the they averaged0.65 ppmF. The averageF intake of 6- to 11- daily intake of beverages (including fruit-flavored month-oldinfants from whole milk, infant formula and bev- juices, carbonated and noncarbonated soft drinks, juice erages wasestima ted to be 0.23 mg/dayor 0.02 7 mg/kgof body concentrate and mineral/spring water) in Hong Kong weight which is about half of the optimumF intake of 0.05- during 1983 was estimated to be 0.15 liters/person. Of 0.07 mg/kg of body weight. this amount, 76%is from carbonated soft drinks (Hong KongDepartment of Census and Statistics 1984). In the Recent studies have shown that the decline in the United States the average per capita consumptionof soft prevalence of dental caries has occurred not only in drinks is estimated to be 419.5 (355 ml, 12-oz) cans optimally fluoridated communities where the drinking during 1982 (Ismail et al. 1984). Four of 10 American water contains fluoride (F) concentrations of 0.7-1.2 toddlers consumed soft drinks in 1977 (Ritzek and ppm, but also in F-deficient communities.1 It has been Jackson 1980). The sale of one brand of spring water suggested that the general decline in dental caries (Perrier) reached 23 million bottles per annumin the prevalence may be due to an increase in the use of F United Kingdom in 1979, while sales in the United dentifrices and mouthrinses, F supplements, and foods States reached an average of 400 million liters per an- and beverages processed with fluoridated water2 and num between 1978 and 1982 (MacFadyen et al. 1982). other reasons. Because of the probable changes in die- With increased industrial pollution of water supplies, ’ Glass1982; Thylstrup et al. 1982;Rao 1984; Marthaler 1984. 3Rozierand Dudney 1981; Driscoll et al. 1982;King and Wei 1986. 2Ericssonand Wei1979; Singer and Ophaug 1979; Messer and Walton SanFilippo andBattistone 1971;Adair and Wei 1979; Taves 1983; 1980;Leverett 1982. Ophauget al. 1985. PEDIATRIC DENTISTRY: MARCH 1988 ~ VOLUME 10, NUMBER 1 13 mineral/spring waters are increasingly used in the volved separation and concentration of F followed by reconstitution powder or concentrated milk formulas measurement with the F- electrode. for babies and infants. Since acidulated soft drinks can contribute to erosion The aim of the present study was to determine the F of dental hard tissues, the pH and the amount of acid in content of commerically available infant formulas, these drinks may be important factors which influence beverages, whole milk, as well as typical infant foods the erosion process. Hence, the titration values of these provided by hospitals and used in the home. It is com- beverages also were determined as follows: to 10 ml of mon for southern Chinese to make soups with ingredi- decarbonated and noncarbonated beverages, 0.1 M ents such as meat with bones, dried seafoods, and herbs. NaOHwas added, under stirring, using an automatic Therefore, it also was important to include the F content .micropipette. The volume of alkaline required to raise of commonly available soups served in the home and the pH of each sample to 7-7.5 was recorded. Measure- purchased from local resturants. ments were made using a pH-glass electrode (Radiome- ter priM84, Denmark). Materials and Methods The items tested in the present study include 20 Results powdered infant formulas, 15 infant hospital foods, 14 The F concentrations in whole cow’s milk and milk typical Chinese soups, 10 whole milk and dairy prod- products, infant formulas, and hospital infant foods are ucts, and 69 commercially available soft drinks, juices, shown in Table 1. The ionic F concentrations in whole and other beverages. The powdered formulas, whole milk were around 0.01 ppm. The pH of the various milk products, and beverages were purchased in 1986 brands of fresh and long-life milk was approximately from supermarkets across Hong Kong. Soups were 6.5. The pH of acidophilus milk drink was 3.7. Addition collected from homes and restaurants in Hong Kong. of chocolate to milk increased the F concentration by 7- The beverages and whole milk products were analyzed to 22-fold. The total F contents (~tg/g) of infant formu- for their ionic F concentrations (~g F/ml), while the las were found to range between 0.06 and 1.08 ppm, with concentrations in powdered formulas, foods, and soups an average of 0.39 ppm F. If the infant formulas were represent the total F content ~tg F/g). Analyses were diluted in a ratio of 1:1 with water containing 0.7 or 1 carried out in duplicate or triplicate. ppm F, the dosage of F would be about 55- and 70-fold Prior to ionic F determination, carbonated beverages more than that obtained from cow’s milk or breast milk. were decarbonated by stirring magnetically for 30 min Hospital infant foods were found to range from 0.27 to at room temperature. Aliquots of decarbonated bever- 0.93 ppmF ~tg/g) with an average F content of 0.59 ppm. ages were mixed with 10% by volume of TISAB III There was less variation in F content of hospital infant (Orion #940911) adjusted to pH 5.5 with NaOH. foods than in infant formulas. The F content in hospital Samples of whole milk also were mixed with TISABIII foods likely reflects the F content of the drinking water (pH 5.2). The TISAB contained 2% of CDTA(1,2-di- of 0.7 ppm. aminocyclohexane N,N,N’, N’-tetraacetic acid), The total F content in the typical soups ranged be- metal-chelating agent which decomplexes F and there- tween 0.32 and 1.66 ~tg/ml with an average of 0.68. The fore makes it available for measurement. The F-concen- relatively high F concentrations in someof the soups are trations were determined using a bank of five combina- due mainly to the inclusion of seafoods and bones in the tion F- electrodes (Orion #960900) coupled with a micro- preparation. Thus, the dosage of F in a bowl of soup processor ionalyzer (Orion #901). The reproducibility (approximately or equal to 250 ml) may contain as much electrode measurements were checked on NaF standard as 0.42 mg F, assuming the F content was 1.66 ~tg/ml. solutions buffered in the same manner as samples. The The ionic F concentrations and pH of the beverages F concentrations in the standard solutions ranged from are presented in Table 2 and in the Figure (page 16). For 0.01 to 0.1 ppm and from 0.025 to 1.0 ppm. The elec- the seven different commercially marketed mineral/ trodes were preconditioned by soaking in a buffer con- spring waters only trace amounts of F (0.01-0.10 ppm) taining F in a concentration corresponding to the lower were detected; however, Ramlosa® was an exception limit of the F concentrations measured. In a separate and it contained the highest F concentration of all tested experiment, the effect of polyvalent ions in complexing beverages. The pH of the different waters ranged from F- was determined in I ppmF (as NaF) solutions contain- 5.7 to 8.1. The F concentrations of canned soft drinks ing 2.5 ppm AP÷, 10 ppmFe 3+, or 100 ppm Mg2+ and then (carbonated) ranged from 0.02 to 0.78 ppm (/~g/ml).