22 October 2001

1. Safety of Fluoride
2. Infant with Easy Bruising
3. Tailbone Tumor
4. Eating Newsprint
5. Insulin Resistance
6. Lump by Anus
7. Maternal Bond
8. Birth Size Relationship to Adult Size
9. Disclaimer

• Read Questions & Answers in Another Column

Safety of Fluoride

-JS

Dear JS: The idea that fluoride is dangerous has a popular cult following on the fringe, but I have yet to read an article in a reputable journal declaring fluoride unsafe. Your pediatrician's statement (if you are quoting it correctly) that he prescribes fluoride because it is okayed by the FDA is preposterous. The FDA can approve drugs as safe and specify what indications may be officially listed for the medications, but the FDA does not recommend practice or prescribing guidelines.

Fluoride is prescribed because it prevents cavities. It is started before your baby's teeth come in because its incorporation into the developing teeth is what strengthens them, making them resistant to cavities. The fluoride supplement is not being applied to the teeth.

You say that as a chemist you are aware of the toxic effects of fluorine buildup in the body, but the fluoride dose prescribed does not cause a buildup in the body. Fluoride binds in the bones and teeth. It is known that too much fluoride is bad for the teeth, and as a result, the guidelines for dosing fluoride were adjusted downward a few years ago. All of my children took fluoride and have good teeth as a result. I am not aware of any ill effect the fluoride had on them.

Sincerely,
Dr. Warren

For many years now, controversy has raged over whether fluoride should be added to drinking water. As early as 1961, as recorded in the Congressional Record, fluoride was exposed as a lethal poison in our nations's water supply. Proponents say that fluoride occurs naturally and helps develop and maintain strong bones and teeth. Opponents to fluoridation contend that when fluoridated water is consumed regularly, toxic levels of fluorine, the poisonous substance from which fluoride is derived, builds up in the body, causing irreparable harm to the immune system. The Delaney Congressional Investigation Committee, the government body charged with monitoring additives and other substances in the food supply, has stated that "fluoridation is mass medication without parallel in the history of medicine."
Meanwhile, no convincing scientific proof has ever been generated that fluoridated water makes for stronger bones and teeth. It is known, however, that chronic fluoride use results in numerous health problems , including osteoporosis and osteomalacia, and also damages the teeth and leaves them mottled. The salts used to fluoridate our nation's water supply, sodium fluoride and fluorosalicic acids, are industrial byproducts that are never found in nature. They are also notoriously toxic compounds, so much so that they are used in rat poison and insecticides. The naturally occurring form of fluoride, calcium fluoride, is not toxic---but this form of fluoride is NOT used to fluoridate water.
Today, more than half the cities in the US fluoridate their water. In many states, it is required. Although many ailments and disorders--including Down Synrome, mottled teeth, and cancer--have been linked to fluoridated water, fluoridation has become the standard rather than the exception.
The fluoride added to tap water can be a problem. Individuals have different levels of tolerance for toxins such as fluoride. In addition, many water sources have levels of fluoride higher than one part per million, the level generally recognized as safe and originally set as the acceptable limit by the EPA. After the EPA learned that water in many towns had natural fluoride levels much higher than this, in fact-- to four parts per million. And this is in addition to fluoride encountered from other sources. Fluoride is the thirteenth most widely distributed element on earth, so it can turn up just about anywhere--in vegetables and meats, for example, Since so many local water supplies are fluoridated, there is a good chance that virtually any packaged food product made with water, such as soft drinks and reconstituted juices, contain fluoride. Additional fluorides are widely used in toothpaste products, so it is easy to see how many Americans may be ingesting excessive amounts of this potentially toxic substance.

Thank you.

-the Grandma

Dear Grandma: I'm going to quote one section of your quote back to you as a lead in to my answer. You quote Dr. Balch as stating, "As early as 1961, as recorded in the Congressional Record, fluoride was exposed as a lethal poison in our nation's water supply. Proponents say that fluoride occurs naturally and helps develop and maintain strong bones and teeth. Opponents to fluoridation contend that when fluoridated water is consumed regularly, toxic levels of fluorine, the poisonous substance from which fluoride is derived, builds up in the body, causing irreparable harm to the immune system." The inflammatory tone of this rhetoric sets the stage for the discussion that follows. It is not conducive to an objective analysis of the data, so if you seek facts, I would suggest you look at his references. Look particularly for studies in scientific journals in which actual data was analyzed and in which control groups were used to establish that any reported effect was a result of fluoridation and not some other confounding variable. If the study uses animal experimentation in which whopping doses of fluoride are used, be careful about extrapolating the data to the human experience at the recommended fluoride dosage.

The nature of medications is such that many of them are toxic at high doses, while providing the desired effect at proper dosages. Even a medication with an excellent safety profile like Tylenol can cause irreversible liver damage if taken chronically in excessive amounts. Vitamin A in high doses will cause the brain to swell. When babies get the nutrients in formula they thrive, but if someone inadvertently feeds them formula concentrate without properly diluting it, even though they get the same nutrients, they become dehydrated and their blood sodium levels become too high. We all know that the body depends on water, but if you feed newborns excessive amounts of water, not only do they gain poorly because of their decreased nutrient intake, but their blood sodium levels now fall too low. My point.... any statement about the toxicity of fluoride must look at its use at the recommended dose.

That having been said, the article you quoted is an argument against the fluoridation of water, not against giving fluoride supplements to children. Let me assure you that I am not a proponent of water fluoridation. The problem with fluoridation is that there is no control over the amount of fluoride a person gets since it depends on his degree of exposure to fluoride in the water supply rather than a standard dose. In addition, we only prescribe fluoride until 14 years of age. Fluoridation exposes a whole population to fluoride well beyond the age that their teeth have finished developing. Still, some feel that it is an effective and inexpensive means of providing a large population with a particular benefit. There is no question that fluoride reduces cavities. In some respects, it is similar to a mass immunization program in which a whole community becomes protected against a disease. A small number of those immunized will suffer ill effects form the vaccines, but had they not been immunized, larger numbers would have suffered more egregiously from an epidemic. Fluoride is not the only additive to which the public has been exposed for public health reasons. Iodine, which is also known to be a toxic substance, is added to salt to prevent iodine deficiency which causes hypothyroidism. Most people buy iodized salt without thinking twice about it. Of course, people have more of a choice than if it were added to the public water supply.

I do not suggest we complacently offer children fluoride without thinking twice about it. A few years ago the recommendations for fluoride dosing were revised to reflect the fact that the doses recommended then were causing mottling of teeth. Continued surveillance of the response to fluoride should help us be sure we are prescribing appropriate amounts. While I don't favor water fluoridation, I certainly recommend a prescribed dose of fluoride to prevent cavities.

Sincerely,
Dr. Warren

-JM

Dear JM: Some infants have very sensitive skin and may develop rashes easily, which in the extreme, may look somewhat bruised; however, no baby, even a newborn, should get bruises just from being touched. Have your pediatrician look at these bruises to determine if there is a need for further evaluation.

Sincerely,
Dr. Warren

-Grandma N

Dear Grandma N: The surgeon may have had a frozen section pathology done at the time of surgery, but this kind of examination is not as complete or definitive as the full pathology examination which takes too much time to do to have available at the time of surgery. While the additional surgery results in an additional anesthesia, the risks of going closer to nerve roots with the potential for nerve damage and dysfunction as a result, are not greater because of the second surgery. It is, in fact, these risks which prevented the surgeon from being more aggressive at the first surgery if he thought he could get the whole tumor with what he did.

Since I don't know the nature of your granddaughter's tumor, I cannot be sure who is the best specialist to consult, but if there is a risk of damage to spinal nerves or nerve roots from the surgery, it might be reasonable to consult a pediatric neurosurgeon.

Sincerely,
Dr. Warren

-Tara

Dear Tara: I know there was some concern about the amount of lead which might be found in newsprint and colored inks in magazines; however I was unable to find any articles indicating that indeed there was ever any evidence found that this was a problem. In any event, it is reasonable for you to prevent your daughter from eating paper, printed on or blank. If she does eat some paper, I don't think you need to be alarmed. There isn't so much toxic material in newsprint or colored inks that a person would become poisoned from eating an occasional piece of a magazine.

Sincerely,
Dr. Warren

My questions, is there any medicine she can take to get the insulin to start working. He diet has always been fresh fruits and veggies, bake fish, chicken (all from organic sources), no junk food - just healthy eating. I need some kind of help. The kids are already calling her fat, etc. She is taller than most 7 year olds.

I look forward to your reply soon.

-AS

Dear AS: Insulin resistance generally is caused by obesity. I am not aware of any medication which will provide a simple solution to your daughter's problem. People who are overweight have bodies which conserve energy efficiently. In times of famine, they have a survival advantage, but in affluent countries where food is plentiful, they develop the problems associated with overnutrition. Your daughter may not eat more food than her normal weight peers, but no matter what the cause of her excess weight gain, she has to be eating more calories than her body burns. She should have a thorough evaluation by an endocrinologist to be sure that no glandular problems are contributing to her obesity, but her large height and early development are typical of overnutrition. The only treatment for obesity caused by overnutrition is to cut the caloric intake by changing the types and amount of foods consumed, and to increase the number of calories burned by increasing the activity level. Exercise aimed at toning and increasing muscle mass is beneficial because an increased muscle mass burns more calories. Aerobic exercise like walking, running, bicycling, swimming, cross country skiing, jazzercise, step aerobics, etc. is the key to burning more calories. Your daughter became overweight a few calories at a time. She can only safely lose the excess weight and maintain good health a little at a time. Sticking with the program consistently over a long time is the only way to be successful. Please read my article, Obesity.

Sincerely,
Dr. Warren

I am a twenty-eight year old male. In the past several years, I've had a variety of skin problems: chelitis, cystic acne, folliculitis (sp?) and, last year, according to a doctor who treated me in South Korea, shingles.

Now I have a cherrypit-sized growth or polyp beneath the skin next to my anus. The surface skin in the area of the growth is not reddened or painful. The growth itself is not particularly painful. This is probably nothing, but I am embarrassed to go to a doctor about it and would like to know whether it is anything I should worry about. I have had hemorrhoids since I was fourteen years old. I am now taking doxycycline for acne ( I've been taking it for four years ) and Seroxat for a mild case of depression.

Thank you for considering my problem.

Sincerely,
-LK

Dear LK: The lump you describe could be a hemorrhoid. If it is firm, it could be a thrombosed hemorrhoid. It could also be from a fissure or an abscess. It certainly doesn't have to be serious, but I can't tell you what it is or how it should be treated without seeing it. Don't let embarrassment stop you from seeking medical attention. I understand why your anus is a personal and private matter to you, but your doctor has seen a lot of anuses, and is aware of how embarrassing this situation is. He should be able to help you through the examination without compromising your sense of dignity.

Sincerely,
Dr. Warren

For example my two "what-ifs" are:

1) What if the child has had continuous care, every other weekend since birth, from one person and the mother (at age 3) gives the child into the custody of his father --- will the one person that has been the only continuous caregiver (albeit only every other weekend) become the person to invoke "materal" bonding?

or

2) What if a child is in daycare from six weeks of age, and has continuous, loving care from one or two individuals. Will a maternal bond be formed with one or both of the caregivers since "time-wise" more is spent with the caregivers?

Thanks for your insights and opinions.

-KH

Dear KH: There may be some physical components to the maternal infant bond. We know that the nursing infant responds to the smell of his mother's milk. There is also evidence that hormones present immediately after delivery affect a mother's bond with her infant, and that delays in allowing mothers to bond with their infants increases the risk of abandonment.

That having been said, let's not get hung up on the word "maternal" in discussing bonding and caregivers. While it is certainly beneficial and preferable for children to be raised by both a mother and father, children who have been raised by only a father can do well just as children raised by only a mother can. Children who are in foster care or who are adopted at varying stages of life certainly bond with their caregivers. Children also bond with baby-sitters and teachers. A child who has been cared for by a baby-sitter or nanny for many years may suffer a significant period of mourning on her departure. The three year old you mention will probably experience some grief on the loss of his mother; however, it may only be a minor adjustment if the relationship with his mother continues with the new custody arrangement.

As children get older, they become more aware and dependent on permanence of a relationship. While children can form strong bonds with new caretakers, such as stepparents, if the people who are important to a child keep disappearing to be replaced by others, the child will learn not to form bonds to spare himself the pain of separation. Thus, a child who loses his parents to a catastrophe will mourn the loss of his parents but will form bonds to his new "parents" if he can depend on the relationship, but if the same child is shuttled from home to home, he will insulate himself from forming a bond.

The amount of time spent with a person caring for a child is certainly not the sole or even main determinant of what kind of bond will form. Children who are old enough to understand relationships may maintain a strong bond to a parent with whom they already have a loving relationship, even in the face of prolonged separations. Those children may not be inclined to form relationships with people they view just as caregivers. While they may come to depend on the caregivers, they may understand that the position is not permanent and is under the control of a parent. On the other hand, most children will respond to genuine love by forming a loving relationship, whether the person is hired help or a stepparent.

Unfortunately, the issue becomes more complex when a child is old enough to have an opinion on the matter of divorce since the child may view the stepparent as an obstacle to having his family reunite and may resent any effort of the stepparent which he perceives as an effort to replace his parent.

Sincerely,
Dr. Warren

-N

Dear N: Very little can be said about adult height or weight based on a child's size at birth. While genetic factors certainly influence birth size, the main determinant of birth size is placental nutrition. Therefore, the duration of the pregnancy and the function of the placenta have more to do with birth size than genetics.

Sincerely,
Dr. Warren

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