When are multivitamins (MVs) recommended for children?

Multivitamin Recommendations for Children

General Healthy Children

Multivitamins are generally NOT recommended for healthy children who consume a balanced diet, as most can achieve adequate nutrient intake from food alone. 1, 2, 3

• Healthy infants and toddlers do not need routine multivitamin supplements if they consume vitamin D-fortified milk, adequate vitamin C sources, and iron-fortified cereals or formula 1
• Children aged 2-8 years typically have nutritionally adequate diets regardless of supplement use, with minimal prevalence of inadequate intakes from food alone 2
• The 2015-2020 Dietary Guidelines for Americans recommend meeting nutritional needs primarily through food consumption, with only specific supplements recommended under particular conditions 4

Specific Indications for Multivitamin Supplementation

Vitamin D Supplementation (Universal Recommendation)

• All infants should receive 400 IU/day of vitamin D, and children/adolescents should receive 400-600 IU/day 5
• Exclusively breastfed infants particularly need vitamin D supplementation, as breast milk contains insufficient amounts 1
• This is one of the few universal supplement recommendations for otherwise healthy children 5

Children on Parenteral Nutrition

Specific multivitamin formulations are required with precise dosing 5:

• Preterm infants: Require specialized vitamin preparations due to limited adaptive capacity to high or low dose intakes 5
• Term infants (0-12 months): Weight-based dosing for all vitamins 5
• Children and adolescents (1-18 years): Fixed daily doses as outlined in parenteral nutrition guidelines 5

Malnutrition and Food Insecurity

• Severely malnourished children (weight-for-height Z-score <-3) require therapeutic feeding programs with multivitamin supplementation 5
• Children in refugee or famine-affected populations need systematic vitamin A supplementation (200,000 IU every 3 months for children 12 months-5 years) 5
• Vitamin A supplementation is indicated when general rations provide <2,000-2,500 IU/person/day 5

Restrictive Diets or Malabsorption

• Children with restrictive diets (vegetarian/vegan, food allergies, selective eating) may benefit from targeted supplementation 6
• Malabsorption conditions (cystic fibrosis, alpha-1-antitrypsin deficiency, cholestasis, biliary atresia) require vitamin supplementation, particularly fat-soluble vitamins 5, 7

Very Low Birth Weight Infants

• Vitamin A supplementation reduces death or oxygen requirement at one month and decreases oxygen requirement at 36 weeks post-menstrual age in infants <1500g 5
• These infants have less adaptive capacity to vitamin intake variations and may require specialized preparations 5

Common Pitfalls to Avoid

Risk of Excessive Intake

• Supplement use significantly increases the likelihood of intakes above the Tolerable Upper Intake Level for iron, zinc, copper, selenium, folic acid, and vitamins A and C 2
• Among toddlers taking supplements, 97% had excessive vitamin A intake and 60-68% had excessive zinc intake 3
• Vitamin A toxicity: Prolonged intake >10,000 IU/day or serum 25(OH)D >375 nmol/L causes hypercalcemia 5

Nutrients Commonly Deficient Despite Supplementation

• Calcium and vitamin D remain inadequate in >one-third of children even with supplement use 2
• Among children 9-18 years, inadequate intakes of magnesium, phosphorus, and vitamins A, C, and E persist despite supplementation 2

Inappropriate Use Patterns

• Approximately 34% of U.S. children use dietary supplements, but most users already have adequate nutrient intakes from food 4
• Supplement users typically do not have nutritionally inferior diets compared to non-users—they are adding supplements to already adequate intakes 2, 3
• First-born children, those labeled as "picky eaters," and those in higher socioeconomic households are more likely to receive supplements despite not having greater nutritional need 3

Clinical Approach

When evaluating need for multivitamins:

1. Assess dietary intake quality rather than assuming need based on parental concern 2, 3
2. Identify specific risk factors: exclusive breastfeeding (vitamin D), malabsorption disorders, severe dietary restrictions, malnutrition 6, 1
3. Prescribe targeted single-nutrient supplements rather than broad multivitamins when specific deficiencies are identified 6
4. Monitor for excessive intake in children receiving both fortified foods and supplements, particularly for vitamin A, zinc, and folate 3