Written by Dr Nické Theron, Pediatrician, blog: Pediatrics and Playdough.

I am sure you know the feeling of standing in the aisle at Dischem, looking at all the bottles and gummies and syrups that says, “Multivitamins for Children”… It can be very confusing to decide what your child needs.

But do children even need supplements? When and how much?  Let us look at some facts:

Vitamins are organic substances produced by plants or animals, while minerals are inorganic elements found in the ground and water, and taken up by plants or ingested by animals. Our bodies need both to function normally. The best source of Vitamins and Minerals is found in fresh food.

Vitamins A, D, E and K are fat-soluble and are stored in your liver, making toxic overdoses possible. The B and C vitamins are water-soluble, so any excess of the vitamin in your body is usually expelled in your urine (making very expensive urine if you drink high dosages for a long time).

During pregnancy the baby can get all the necessary vitamins from mom. Vitamins B and C are transferred via the placenta throughout pregnancy. Vitamins A, D and E are transferred in the last trimester (so preterm babies may miss out on this).

Breastmilk from mothers with enough vitamins in their own body, supplies enough vitamins to their babies. Except for Vitamin D and K. Baby has to rely on the synthesis of Vitamin K by gut bacteria, and on synthesis of Vitamin D via sunlight if no other supplements are given. Formula milk is supplemented with most vitamins and minerals.

After 6 months babies need to get more vitamins and minerals than either milk can provide, and that is why solids need to be introduced at this age.

Deficiencies develop when a specific vitamin or mineral is critically low in our bodies, causing specific clinical signs and symptoms.

Who is at risk for Vitamin deficiencies?

• Picky eaters
• Children on Vegan / Vegetarian / Diary-free diets
• Premature babies
• Malnourished children
• Infants of mothers with vitamin deficiencies
• Children with chronic diseases that hinders absorption of certain vitamins

For example, children who eat plant-based diets are at risk of deficiencies in Calcium, Iron, Zinc, Vitamin B12 and Vitamin D which are most prevalent in animal products.

We all want to give our children the best… but what is the best for them? Even the expert-guidelines do not always agree on this:

• Association for Dietetics in South Africa: Diet is the best source of vitamins and minerals, supplements are not necessary for all children.
• UK: All children aged 6months – 5 years should have daily vitamin supplements containing Vitamin A, C and D.
• American Academy of Pediatrics: Children who eat a balanced diet do not need supplements.

However, there is good evidence about the supplementation of specific vitamins and minerals. Let me give you a few more specific guidelines about these:

Vitamin A:

South Africa has identified that about 33% of our children are Vitamin A deficient. We started a supplementation program where each child can get Vitamin A every 6 months.

Vitamin A supplementation can decrease the number of respiratory infections and diarrhea, and improve the outcome of measles.

Suggested:

Vitamin A 100 000 IU at 6 months and then Vitamin A 200 000 IU every 6 months. This should be given at your local clinic where your child is vaccinated and should be recorded in the Road to Health Booklet.

Vitamin D:

Breastmilk does not contain enough Vitamin D and babies are mostly kept out of the sun to protect their delicate skin. Vitamin D deficiency can cause bone (rickets) and immune issues.

Suggested:

All breastfeeding infants should receive Vitamin D 400 IU daily from birth until at least 500 ml of Vitamin D rich milk is consumed daily.

Vitamin K:

Babies are born with very low stores of Vitamin K. An infant’s gut is sterile and there is very little Vitamin K in breastmilk. Vitamin K is critically important in the clotting cascade. If a baby is deficient (usually by day 2 – 5 of life) they are at a risk of bleeding that may be fatal. After a few days of life, the microbiome in the gut starts to produce Vitamin K in sufficient amounts.

Suggested: Vitamin K 1 mg injected in a muscle within 6 hours after birth.

Iron:

Term, healthy infants usually have enough iron in their bodies for the first 5 – 6 months of life. Breast milk contains very little iron, but it is very easily absorbed.  Formula milk is usually supplemented with iron. After 6 months of age the iron requirements increase rapidly, and thus breastmilk alone is not enough to sustain the iron-needs in babies. They need to take in extra iron in some form. 

Suggested:

All exclusively breastfed infants – Supplemental Iron 1 mg/kg/day from 4 months until eating 2 meals of iron rich foods per day. Thereafter iron supplementation should be individualized according to your child’s need. Read more here in my articles about iron deficiency: https://pediatricsandplaydough.com/2019/12/02/iron-deficiency/

https://pediatricsandplaydough.com/2019/12/19/iron-deficiency-anemia-treatment/

Zinc:

Zinc supplements given when cold symptoms or diarrhea start, has been proven to reduce the severity or shorten the length of symptoms. When taken long term in high doses (4 mg a day under 6 months) it can lead to copper deficiency. Iron and Zinc competes for absorption and therefore it can interfere with iron absorption.

Suggested:

Take Zinc 0.5 – 1 mg/kg daily when child has cold / diarrhea.

Omega 3 + 6:

These are essential nutrients that the body cannot make. Plays a role in brain development and brain function (especially learning and memory). Biggest effect in children with ADHD.

Suggested:

Take supplements antenatally. Can be beneficial in school aged children with learning problems.

Probiotics:

Probiotics are microbes that are not harmful, and that have a beneficial effect on you when taken in an adequate amount. Prebiotics are non-digestible carbohydrates that “feed” the good microbes in the gut.

Efficacy of probiotics is both strain– and disease-specific, and any probiotic must be provided in adequate amount. So you need to know which specific strain helps for which problem. “Cold” probiotics are not necessarily more effective than the drops / tablets.

If you drink a “cocktail” of probiotics it might help to keep your microbiome healthy in general, but only specific strains have been proven to give the following benefits in the following cases:

• Acute diarrhea: reduce duration
• Antibiotic associated diarrhea: reduce risk
• Irritable Bowel disease: reduce symptoms
• Prevention of NEC in premature babies
• Colic: prevents colic, reduces crying time
• Prevention of infections: reduces respiratory illnesses, ear infections and need for antibiotics
• Autism: improves severity

(Discuss the specific type with your doctor if you want to treat a specific problem).

Ok, so let us talk about the multivites…

In general, it is almost impossible to say that one is better than another. The most common vitamins and minerals are usually all present, and although the gummy bear might feel more important than the chewy tablet because it has some extra iron or selenium, or 0.001mg more Vitamin C, it is not necessarily going to make a difference for your child. Depending on the needs of your child, you could go “back to basics” and skip all the fancy bottles. Cod liver oil contains high levels of Vitamin A, D and Omega 3, which might decrease inflammation and improve bone and eye health. (We all remember drinking our Scott’s Emulsion).

It is very difficult to say how much of each vitamin “should be” in your multivite, as it is almost impossible to know how much you are getting from your diet (unless you work closely with a dietitian). Below you will see a table with a “Daily Recommended Intake” (also indicated as Recommended Daily Allowance) for the most important vitamins and minerals. As long as your supplement contains less than these amounts it should be safe. Remember that certain cereals, maize meals and milk are also supplemented with vitamins and minerals, make sure that you add those to your calculations.

I know we are also giving our kids supplements in the hope that they will not be affected by the dreaded viruses that circulate this time of the year. We know that Vitamins A, C, D and Zinc play a big role in your immunity. The gut microbiome is part of your immune system’s first line of defence  and certain probiotics have been proven to reduce respiratory diseases. There are also many plant extracts that are beneficial in the fight against viruses, for example Echinacea has been proven to reduce infections and symptoms.  See this article for more information: https://pediatricsandplaydough.com/2021/04/28/treatment-of-runny-noses-colds-flu/

I will say it again: FOOD is the BEST source of vitamins and minerals. All other commercially available vitamins are synthetic, and although effective, the benefits from natural vitamins surpass them on a variety of levels.

So, in the end you need to decide which risks your own child has, and choose supplements accordingly. Ask your healthcare worker for advice and remember…

If you supplement:

• Discuss the dose and duration with your healthcare worker.
• Available as drops, syrups or chewable tablets.
• Keep the bottles out of reach, most supplements look and tastes like sweets! Overdose is possible.

If you do not supplement:

• Make sure your child eats a variety of healthy foods.
• Remember that heat destroys vitamins.
• See your health care worker for well-child checkups to screen for any symptoms of deficiencies.

Please let us know which supplements work well for your little ones!

Resources:

1. Leaf AA, RCPCH Standing Committee on Nutrition; “Vitamins for babies and young children”; Arch Dis Child; 2007 Feb; 92(2): 160-164
2. Coovadia HM, Wittenberg DF; Paediatrics & Child Health; 5^th edition
3. Greer FR, “Do breastfed infants need supplemental vitamins?”; Pediatr Clin North Am; 2001 Apr; 48(2):415-23
4. Hsieh MH, Versalovic J; “The Human Microbiome and Probiotics: Implications for Pediatrics”; Curr Probl Pediatr Adolesc Health Care. 2008 Nov–Dec; 38(10): 309–327.
5. Hsieh MH; “The Microbiome and Probiotics in Childhood”; Semin Reprod Med. 2014 Jan;32(1):23-7.
6. Hill C, Guarner F, Reid G, et al. Expert consensus document. The International Scientific Association for Probiotics and Prebiotics consensus statement on the scope and appropriate use of the term probiotic. Nat Rev Gastroenterol Hepatol 2014;11:506–14. 
7. Marchand V Canadian Paediatric Society, Nutrition and Gastroenterology Committee, Position statement “Using probiotics in the paediatric population” Posted: Dec 3, 2012 | Updated: Jun 18, 2019
8. https://www.healthline.com/nutrition/vitamins-for-kids
9. https://www.healthline.com/nutrition/9-benefits-of-cod-liver-oil#TOC_TITLE_HDR_8