Fluoride is a common natural element found in water, soil, rocks and food. For the past several decades, fluoride has also been a cornerstone of dentistry and public health, owing to its ability to protect against tooth decay.

Water fluoridation is a population-based program where a precise, small amount of fluoride is added to public drinking water systems. Water fluoridation began in Australia in the 1950s. Today more than 90% of Australia’s population has access to fluoridated tap water.

But a recently published review found higher fluoride exposure is linked to lower intelligence quotient (IQ) in children. So how can we interpret the results?

Much of the data analysed in this review is poor quality. Overall, the findings don’t give us reason to be concerned about the fluoride levels in our water supplies.

Not a new controversy

Tooth decay (also known as caries or cavities) can have negative effects on dental health, overall health and quality of life. Fluoride strengthens our teeth, making them more resistant to decay. There is scientific consensus water fluoridation is a safe, effective and equitable way to improve oral health.

Nonetheless, water fluoridation has historically been somewhat controversial.

A potential link between fluoride and IQ (and cognitive function more broadly) has been a contentious topic for more than a decade. This started with reports from studies in China and India.

But it’s important to note these studies were limited by poor methodology, and water in these countries had high levels of natural fluoride when the studies were conducted – many times higher than the levels recommended for water fluoridation programs. Also, the studies did not control for other contaminants in the water supply.

Recent reviews focusing on the level of fluoride used in water fluoridation have concluded fluoride is not linked to lower IQ.

Despite this, some have continued to raise concerns. The United States National Toxicology Program conducted a review of the potential link. However, this review did not pass the quality assessment by the US National Academies of Sciences, Engineering and Medicine due to significant limitations in the conduct of the review.

The authors followed through with their study and published it as an independent publication in the journal JAMA Paediatrics last week. This is the study which has been generating media attention in recent days.

What the study did

This study was a systematic review and meta-analysis, where the researchers evaluated 74 studies from different parts of the world.

A total of 52 studies were rated as having a high risk of bias, and 64 were cross-sectional studies, which often can’t provide evidence of causal relationship.

Most of the studies were conducted in developing countries, such as China (45), India (12), Iran (4), Mexico (4) and Pakistan (2). Only a few studies were conducted in developed countries with established public water systems, where regular monitoring and treatment of drinking water ensures it’s free from contaminants.

The vast majority of studies were conducted in populations with high to very high levels of natural fluoride and without water fluoridation programs, where fluoride levels are controlled within recommended levels.

The study concluded there was an inverse association between fluoride levels and IQ in children. This means those children who had a higher intake of fluoride had lower IQ scores than their counterparts.

Limitations to consider

While this review combined many studies, there are several limitations that cast serious doubt over its conclusion. Scientists immediately raised concerns about the quality of the review, including in a linked editorial published in JAMA.

The low quality of the majority of included studies is a major concern, rendering the quality of the review equally low. Importantly, most studies were not relevant to the recommended levels of fluoride in water fluoridation programs.

Several included studies from countries with controlled public water systems (Canada, New Zealand, Taiwan) showed no negative effects. Other recent studies from comparable populations (such as Spain and Denmark) also have not shown any negative effect of fluoride on IQ, but they were not included in the meta-analysis.

For context, the review found there was no significant association with IQ when fluoride was measured at less than 1.5mg per litre in water. In Australia, the recommended levels of fluoride in public water supplies range from 0.6 to 1.1 mg/L.

Also, the primary outcome, IQ score, is difficult to collect. Most included studies varied widely on the methods used to collect IQ data and did not specify their focus on ensuring reliable and consistent IQ data. Though this is a challenge in most research on this topic, the significant variations between studies in this review raise further doubts about the combined results.

No cause for alarm

Although no Australian studies were included in the review, Australia has its own studies investigating a potential link between fluoride exposure in early childhood and child development.

I’ve been involved in population-based longitudinal studies investigating a link between fluoride and child behavioural development and executive functioning and between fluoride and IQ. The IQ data in the second study were collected by qualified, trained psychologists – and calibrated against a senior psychologist – to ensure quality and consistency. Both studies have provided strong evidence fluoride exposure in Australia does not negatively impact child development.

This new review is not a reason to be concerned about fluoride levels in Australia and other developed countries with water fluoridation programs. Fluoride remains important in maintaining the public’s dental health, particularly that of more vulnerable groups.

That said, high and uncontrolled levels of fluoride in water supplies in less developed countries warrant attention. There are programs underway in a range of countries to reduce natural fluoride to the recommended level.

Loc Do, Professor of Dental Public Health, The University of Queensland

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Neurodevelopmental conditions such as attention deficit hyperactivity disorder (ADHD) and autism affect about one in ten children. These conditions impact development, behaviour and wellbeing.

But children with these conditions and their caregivers often can’t get the support they need. Families report difficulties accessing health-care providers and experience long wait lists to receive care.

Digital tools, such as apps and websites, are often viewed as a solution to these gaps. With a single click or a download, families might be able to access information to support their child.

There are lots of digital tools available, but it’s hard to know what is and isn’t useful. Our new study evaluated freely available digital resources for child neurodevelopment and mental health to understand their quality and evidence base.

We found many resources were functional and engaging. However, resources often lacked evidence for the information provided and the claimed positive impact on children and families.

This is a common problem in the digital resource field, where the high expectations and claims of impact from digital tools to change health care have not yet been realised.

What type of resources?

Our study identified 3,435 separate resources, of which 112 (43 apps and 69 websites) met our criteria for review. These resources all claimed to provide information or supports for child neurodevelopment, mental health or wellbeing.

Resources had to be freely available, in English and have actionable information for children and families.

The most common focus was on autism, representing 17% of all resources. Resources suggested they provided strategies to promote speech, language and social development, and to support challenging behaviours.

Other common areas included language and communication (14%), and ADHD (10%).

Resources had various purposes, including journalling and providing advice, scheduling support, and delivering activities and strategies for parents. Resources delivered information interactively, with some apps organising content into structured modules.

Resources also provided options for alternative and assistive communication for people with language or communication challenges.

Most apps were functional and accessible

Our first question was about how engaging and accessible the information was. Resources that are hard to use aren’t used frequently, regardless of the information quality.

We evaluated aesthetics, including whether digital tools were easy to use and navigate, stylistically consistent, with clean and appealing graphics for users.

Most resources were rated as highly engaging, with strong accessibility and functionality.

But many lacked quality information

We ranked resources on various features from 1 (inadequate) to 5 (excellent), with a ranking of 3 considered acceptable. These ratings looked at how credible the resource was and whether there was evidence supporting it.

Despite their functionality, 37% of reviewed apps did not meet the minimum acceptable standards for information quality. This means many apps could not be recommended. Most websites fared better than apps.

There also wasn’t a lot of scientific evidence to suggest using either apps or digital resources actually helped families. Studies show long-term engagement with digital tools is rare, and downloads don’t correspond to frequent usage or benefits.

Digital tools are often viewed as a panacea to health-care gaps, but the evidence is yet to show they fill such gaps. Digital health is a fast-moving field and resources are often made available before they have been properly evaluated.

What should you look for in digital resources?

We found the highest quality resources were developed in collaboration with institutions, such as health, university or government groups.

One highly rated resource was the Raising Children’s Network and the associated app, Raising Healthy Minds. These are co-developed with a university and hospital, and by people with appropriate qualifications.

This resource provides information to support children’s overall health, development and wellbeing, with dedicated sections addressing neurodevelopmental needs and concerns.

Our research shows parents can assess whether digital resources are high quality by checking they are:

• factually correct. Look for where the app or resource is getting its information. Does the author have the qualifications and training to provide the information? Are they a registered health expert who is accountable to a regulatory body (such as AHPRA, the Australian Health Practitioners Regulation Agency) for providing information that does not cause harm?
• consistent across multiple credible sources, such as health institutions.
• linked to supporting information. Look for reliable links to reputable institutions. Links to peer-reviewed scientific journals are often helpful as those articles will also usually describe the limitations of the research presented.
• up-to-date. Apps should be frequently updated. For websites, dates of update are usually found on the homepage or at the bottom of individual pages.

Beware of red flags

Some things to watch out for are:

• testimonials and anecdotes without evidence and scientific links to back the anecdotes up. If it sounds too good to be true, it probably is.
• no information provided about conflicts of interest. Organisations gain when you click on their links or take their advice (financial, reputation and brand development). Think about what they gain when you use their information to help keep a balanced perspective.

Remember, the app’s star rating doesn’t mean it will contain factual information from a reliable source or be helpful for you and your child.

The role of digital tools

Digital tools won’t usually replace a health professional, but they can support care in many different ways. They may be used to help to educate and prepare for meetings, and to collaborate with health providers.

They may also be used to collect information about daily needs. Studies show reporting on sleep in children can be notoriously difficult, for example. But tracking sleep behaviour with actigraphy, where movement and activity patterns are measured using a wearable device, can provide information to support clinical care. With the promise of artificial intelligence, there will also be new opportunities to support daily living.

Our findings reflect a broader problem for digital health, however. Much investment is often made in developing products to drive use, with spurious claims of health benefits.

What’s needed is a system that prioritises the funding, implementation and evaluation of tools to demonstrate benefits for families. Only then may we realise the potential of digital tools to benefit those who use them.

Kelsie Boulton, Senior Research Fellow in Child Neurodevelopment, Brain and Mind Centre, University of Sydney and Adam Guastella, Professor and Clinical Psychologist, Michael Crouch Chair in Child and Youth Mental Health, University of Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.