Main Points

• The composition of pediatric multi-micronutrient supplements in the Turkish market is characterized by significant heterogeneity and a lack of standardization.
• This market poses a dual risk: subtherapeutic doses of essential minerals, such as calcium and magnesium, which can lead to inefficacy, and excessive doses of vitamins A, D, and zinc that exceed daily maximum limits, potentially leading to chronic toxicity.
• The widespread availability and marketing of these products contradict national health guidelines, which do not recommend routine supplementation for healthy, well-nourished children.
• Stricter regulatory oversight of supplement composition and stronger clinical guidance for parents are urgently needed to prevent both inadequate and excessive micronutrient intake.

Introduction

Background

The popularity of dietary supplements for children, particularly those in the form of flavored gummies and chewables, is on the rise on a global scale. The revenue of the vitamin and mineral market in Türkiye is projected to attain US$29.72 million by the year 2025, exhibiting a compound annual growth rate that is anticipated to exceed both the global rate of 6.7% and the US rate of 7.52% between the years 2025 and 2029, with a projected growth rate of 10.49%.^1,2 This increase in market growth reflects parents’ growing awareness of their children’s nutritional needs and the increasing importance placed on preventive health approaches. Parents commonly regard these supplements as a means of protecting their children against infections and supporting their physical and cognitive development.^3-5

Adequate intake (AI) of micronutrients, including vitamins, minerals, and trace elements, is essential for children’s optimal growth, physical and cognitive development, immune function, and overall health.^6,7 Deficiencies and excesses in these essential nutrients can result in a variety of adverse health consequences, which may have long-term consequences.^7-10 Therefore, nutritional supplements intended for children must provide these essential components within appropriate amounts.¹¹

In Türkiye, the Ministry of Health has established a national policy that stipulates the administration of vitamin K at birth, vitamin D in the first year of life, and iron supplementation between 4-12 months of age (2-12 months in cases of prematurity).^12,13 However, beyond these national recommendations, additional vitamin and mineral supplementation for healthy children who consume a normal and balanced diet is not recommended.^12-15

Aim

Given the expanding market and its potential effects on child health, there is a clear need for data specific to the Turkish context to understand the characteristics of available supplements and their alignment with relevant nutritional guidelines. This study aims to address this gap by analyzing the multi-micronutrient content of dietary supplements marketed for children in Türkiye and comparing it with established national daily nutritional reference values.

Material and Methods

Study design and settings

This was an observational, cross-sectional, descriptive study conducted between April and May 2025. The study was reported in accordance with The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement guidelines (Supplementary Material).¹⁶

The study was conducted in the provinces of Manisa and İzmir to reflect the demographic and socioeconomic diversity of the Aegean Region. These locations were selected based on logistical feasibility and resource constraints. In each province, three districts representing low, middle, and high socioeconomic levels were selected via purposive sampling. Within these selected districts, convenience sampling was utilized to access centrally located pharmacies with high foot traffic. A total of 18 different pharmacies were visited, comprising a minimum of one and a maximum of five pharmacies from each district. This sampling strategy was chosen for its practicality in reaching the maximum number of products within a limited time frame. Since manufacturer formulations are standardized nationally, data from locations were pooled to analyze the widest possible range of unique product brands available in the Turkish market.

The study included all multi-micronutrient supplements that were sold with or without a prescription in the visited pharmacies and had a specific dosage recommendation for children under 18 years of age on their packaging. Products sold online were excluded from the scope of the study due to the difficulty of price standardization and the inability to verify regional availability. Products containing a single micronutrient were excluded from the study. For the purpose of this analysis, multi-micronutrient supplements were defined as any product containing at least two distinct micronutrients or active ingredients in a single formulation, regardless of the total count.

Dietary reference intakes and values

In this field, two main reference value systems stand out globally: the Dietary Reference Intakes (DRI) framework ¹⁷, developed by the Food and Nutrition Board (FNB) of the National Academies of Sciences, Engineering, and Medicine for the United States (US) and Canada, and the Dietary Reference Values (DRV) framework¹⁸, established by the European Food Safety Authority (EFSA) for the European Union. In Türkiye, two different frameworks are used: the Turkish Food Codex (TFC)¹⁹ and the Turkey Dietary Guidelines (TDG).¹⁵ A comparative summary of the dietary reference value terminologies, definitions, and primary areas of application used by the FNB, EFSA, and Türkiye is presented in Table S2 (Supplementary Material). A comparison of the TFC and international DRV is presented as an interactive website at https://onurdersan.github.io/micronutrients/.²⁰

Variables, measurement and procedure

For each product, the name, brand, supplement type, pharmaceutical form (e.g., syrup, capsule, chewable), flavor, the presence of a figure and a child figure on the packaging, the total package quantity, the recommended daily dosages according to age, and the content and amounts of micronutrients (vitamins, minerals) and other active ingredients (e.g., fish oil/fatty acids, herbal extracts) in these dosages were recorded. The products and their contents were verified using the official lists of the Republic of Türkiye Ministry of Agriculture and Forestry and the Ministry of Health, as well as the manufacturers’ official websites. To ensure a homogeneous market analysis, the study specifically included products legally classified as dietary supplements, which are regulated and licensed by the Ministry of Agriculture and Forestry. Products registered as pharmaceuticals under the Ministry of Health were used for exclusion verification and were not included in the final analysis, as they are subject to different regulatory standards regarding labeling and composition.

The number of days a product would last was calculated as [total quantity ÷ daily dose], and the cost per day of use was calculated as [product price ÷ (total quantity × daily dose)]. To ensure international comparability given currency fluctuations of Turkish Liras (TRY), all cost data were also converted to Euros (EUR) based on the average exchange rate during the study period (1 EUR = 43.28 TRY), obtained from the Central Bank of the Republic of Türkiye.

For each micronutrient, product contents were compared with the age- and gender-specific DRVs²¹ and Daily Maximum Limits (DMLs)²² as reported by the TFC¹⁹ (Supplementary Table S2).

Statistical analysis and data visualization

Data analysis and visualizations were performed using the jamovi software (The jamovi project. Sydney, Australia. version 2.3) and IBM SPSS Statistics for Windows (IBM Corp. Released 2021. Version 28.0. Armonk, NY).

The distribution of the data was assessed using histograms, Q-Q plots, and the Kolmogorov-Smirnov test. Continuous variables were summarized as mean ± standard deviation (SD) or median and interquartile range (IQR). Categorical variables were presented as absolute numbers and percentages (n [%]).

Ethical considerations

This study did not require institutional ethics committee approval, as all data was compiled from publicly available sources and it did not involve any human or animal subjects.

Results

A total of 93 products from 28 brands were included in the study. Four products were excluded due to content discrepancies and missing data. Analyses were performed on a total of 89 products from 27 brands (mean, 3.3±3.6; range, 1-13).

Of the products, 48.3% (n=43) were in syrup form, 14.6% (n=13) were chewable tablets, and 12.4% (n=11) were chewable gels. In terms of flavor, 35.96% (n=32) of the products contained orange, 13.48% (n=12) contained mixed fruit, and 13.48% (n=12) contained lemon.

A total of 51.7% (n=46) of the products featured at least one figure on the packaging. Of the 17 different figures, the most common type was an animal (n=33, 37.1%). The most frequently used figure was fish (17 products from 6 brands, 19.1%). A child figure or picture was included on 25.9% (n=23) of the products.

The products contained a supply sufficient for an average of 25.9±12.7 days (range, 10-70) for the 4-10 age group and 23.6±10.2 days (range, 10-60) for the 11-18 age group. The average retail price of the products was 491±216 TRY (11.3±4.99 EUR) (range, 101-1149 TRY, 2.33-26.5 EUR). The average daily cost was 23.3±17.7 TRY (0.54±0.4 EUR) (range, 5.0-100 TRY, 0.12-2.3 EUR) for children aged 4-10 years and 26.6±12.9 TRY (0.61±0.3 EUR) (range, 5.5-53.3 TRY, 0.13-1.23 EUR) for those aged 11-18 years.

The three most common micronutrients found in the products were vitamin C (n=64, 71.91%), vitamin D (n=63, 70.79%), and zinc (n=55, 61.8%). The micronutrient contents and their proportions are presented in Table 1.

The micronutrient amounts in the products were compared with the DRVs established by the TFC for various age groups, and the results are presented as a percentage of the DRV in Table 2, Table 3, and Table 4. The mean ratios of micronutrient levels to the DRV varied widely, ranging from 15% to 1250% for vitamin C, 50% to 750% for vitamin D, and 28% to 40000% for vitamin B12. For the 4-10 age group, the mean daily dose met only 22.8% (±9.9) of the DRV for calcium, 20.6% (±9.1) for magnesium, 41.6% (±10.6) for iodine, and 42.0% (±31.2) for iron. For the 11-18 age group, the mean daily dose met only 24.1% (±4.0) of the DRV for magnesium and 37.1% (±22.5) for vitamin K.

For the 4-10 age group, the mean DRV ratio was less than 100% for 21 micronutrients, whereas the mean DRV ratio for vitamin D was 196%. For the 11-18 age group, the mean DRV ratio was below 100% for 8 micronutrients and above 100% for 14 micronutrients. Regarding other active ingredients, the mean DRV ratio for DHA (Docosahexaenoic acid) was above 100% in all age groups. The mean daily dose of DHA met 326.8% (±206.1) of the DRV for children aged 4-8 years, 245.1% (±154.5) for those aged 9-11 years, and 297.0% (±172.4) for those aged 12-13 years.

A comparison of the ratios of product contents to the DMLs established by the TFC and UL (Upper level of intake) for EFSA is presented in Table 4. In the 4-10 age group, the maximum dose was found to correspond to 467% of the DML for vitamin A, 300% of the DML for vitamin D, 200% of the DML for iron, and 200% of the DML for zinc. In the 11-18 age group, the maximum dose was found to correspond to 125% of the DML for vitamin A and 100% of the DML for both zinc and iodine.

Discussion

To our knowledge, this is the first study to analyze the contents and marketing features of multi-micronutrient supplements for children in Türkiye. The primary finding of the study is the notable heterogeneity in the multi-micronutrient content of food supplements marketed for children in Türkiye. This heterogeneity raises serious concerns regarding the consistency and predictability of nutrient intake when these products are used, as some supplements provide adequate amounts of micronutrients while others fall below or significantly exceed reference values.

National and international guidelines clearly state that healthy children who consume a balanced and varied diet do not require additional multi-micronutrient supplementation. In contrast, our study reveals the existence of a market aimed at the general pediatric population, offering a wide range of products that go beyond the principle of complementing, not replacing, a diet. The significant variation in nutrient content, even among products targeting the same age group, poses a challenge for parents and caregivers attempting to make informed choices. The absence of standardized formulations complicates the selection of an appropriate supplement and may lead to either insufficient or excessive intake, depending on the chosen product. This underscores the need for stronger clinical guidance to bridge the gap between parental purchasing behaviors and the actual health requirements of children.

Parental anxiety and the power of persuasion in marketing

Our study revealed that more than half of the products (51.7%) featured a character or figure on their packaging, and a quarter (25.9%) included a child figure. The fact that the most commonly used figure was a fish (19.1%) is likely a marketing strategy to associate the products with the perceived cognitive benefits of omega-3 fatty acids. Research has shown that cartoon characters on packaging significantly influence children’s taste perceptions and product preferences, creating pester power.²³

This trend is not unique to Türkiye. Studies conducted in the US, China, and other developed countries show that approximately one-third of children use dietary supplements and that multivitamins are the most common type. ^24,25 Parents’ reasons for using dietary supplements are to improve general health, strengthen immunity, and support appetite and diet.^3,4,24,26 Consistent with the parental perception of immune support, the most frequent micronutrients in the products in our study included popular ones such as zinc and vitamins C and D. Similarly, studies analyzing the content of multivitamins and multiminerals in Peru and the US reported that the most common ingredients were vitamins C, D, A, and zinc.^27,28

This marketing approach medicalizes normal dietary diversity and replaces nuanced clinical judgment with a simple consumer choice, which shifts the burden of risk assessment onto parents who lack the necessary tools (such as UL information on labels) to make an informed decision.

The double-edged sword of dosage: Risks of insufficiency and excess

The most central finding of this study is the variability in micronutrient content among the products. This variability creates a dual-risk profile for the consumer: on one hand, the risk of receiving subtherapeutic doses that provide a false sense of security, and on the other, the more concerning risk of chronic exposure to excessive doses that approach or exceed established safety limits.

Our analysis showed that in products formulated for the 4-11 age group, the average content of 21 different micronutrients fell below the TFC DRV. Essential minerals critical for child development, such as calcium, magnesium, and iron for bone health and neurological development, were offered at levels meeting approximately 20-40% of the DRV. While these amounts align with the regulatory definition of a supplement intended to complement a varied diet, they may be considered subtherapeutic in the context of parental reliance. Parents often use these products to address perceived dietary inadequacies, yet these dosages may be insufficient to correct actual deficits, creating a gap between consumer expectation and physiological impact. This finding of our study was consistent with other research. A study in the US found that while many vitamins were provided at or above the Recommended Dietary Allowance (RDA), calcium, magnesium, and phosphorus were consistently labeled below the RDA.²⁹ A market analysis in Canada revealed that the median doses of calcium and iron in pediatric supplements were similarly low.³⁰

Although product labels technically declare these amounts in compliance with regulations, the marketing of these products as comprehensive ‘multivitamin/multimineral’ formulations can create a paradox. Parents who purchase these supplements may believe they are meeting their children’s nutritional needs under the perceived illusion of comprehensive nutritional support, while in reality, the subtherapeutic doses of essential minerals mean their children may still be at risk for essential mineral deficiencies. This false assurance can deter parents from seeking dietary solutions or using appropriate, single-ingredient supplements when clinically indicated.

Conversely, the prolonged use of such supplements, especially when combined with dietary intake, may lead to exceeding safe upper limits and potentially result in adverse health effects.^31,32 Table 5 illustrates the potential risk by comparing it with the safety thresholds established by the TFC. Our findings align with research from Canada, where median doses of vitamins A, B6, B12, and C, as well as other B vitamins, were found to significantly exceed the AI recommendations.³⁰ Another study in Danish children found that a significant proportion of those using multivitamin and mineral supplements exceeded the ULs for micronutrients such as vitamin A, zinc, iodine, and iron.³³ Similarly, Saavedra-Garcia et al. reported that vitamin A and folate most frequently exceeded the recommended UL.²⁷ In their study evaluating the micronutrient content for children aged 1-3 years, Samuel et al. reported that more than one-third of the products contained Vitamin A that exceeded the UL, and one-fifth contained niacin that also exceeded the UL.³⁴

Therefore, the study’s findings have important implications for clinicians. Clinicians should proactively inquire about all supplement use and document brand names and dosages. As physicians are the most frequent source of information, they have a critical role in educating parents about the lack of evidence for routine multivitamins, specific national recommendations for vitamin D and iron, and the dangers of toxicity from over-the-counter products.⁵ This critical role is further reinforced by the finding in the study by Koç et al. that “72% of families believe that excessive use of nutritional supplements is not harmful”.⁵

Study Limitations

This study has several limitations. First, it was conducted within a specific time frame and a limited geographical area using a convenience sampling method; therefore, while it captures nationally distributed brands, the findings may not be generalizable to the entire national market. The study provides a snapshot of the market, a limitation that should guide future research, as formulations and product availability can change rapidly. This cross-sectional design may introduce seasonality bias, as certain formulations predominantly marketed for winter use (e.g., specific immune boosters) might be underrepresented compared to peak-season availability. Licensed products that were unavailable on the market could not be included in the study. The exclusion of online marketplaces restricts our findings to the traditional retail pharmacy sector, where parents typically seek professional face-to-face guidance, potentially missing online-exclusive brands. Furthermore, the analyses are based solely on the nutritional content declared on product labels and manufacturers’ official websites and do not include independent chemical analysis. However, significant research shows that the actual content of nutritional supplements often deviates from label declarations.^29,35,36 We acknowledge that web-based data may lag behind physical labeling updates. Therefore, our findings reflect the declared safety profile presented to the consumer rather than the analytically confirmed composition. A major limitation of our study is the lack of separate DRV data for age and gender in the TFC.

In light of these findings, future research could focus on conducting laboratory analyses to verify label claims, investigating the impact of pediatric nutritional supplement use on children’s overall nutrient intake and micronutrient status, examining the knowledge and attitudes of parents in Türkiye regarding these products, and evaluating the long-term health outcomes associated with their use.

Conclusion

The market for multi-micronutrient supplements marketed for children in Türkiye is characterized by remarkable heterogeneity and a lack of standardization in product content. This situation creates a dual-risk profile for children. On one hand, the provision of subtherapeutic doses of essential minerals such as calcium, magnesium, and iron may create a false sense of security in parents, thereby failing to address existing nutritional deficiencies. On the other hand, the presence of micronutrients, particularly vitamins A and D and zinc, in doses exceeding the nationally established DML, carries a risk of chronic toxicity and excessive intake.

The current market structure contradicts national and international health guidelines that do not recommend such supplements for healthy, well-nourished children. Marketing strategies, such as figures on packaging, create a market shaped by consumer demand, targeting parental anxiety rather than evidence-based medical necessity. In light of these findings, clinicians should counsel families on the non-necessity of routine use of these supplements, actively inquire about the products and dosages being used, and educate them on the potential risks of toxicity. Policymakers should more strictly regulate the content and labeling standards of supplements for children, incorporate safety limits such as the UL into legislation, and oversee misleading marketing practices. Future research should verify label claims with chemical analyses and evaluate the long-term health outcomes of these products.

In conclusion, the multi-micronutrient supplement market for children in Türkiye presents a picture that carries risks of both insufficient and excessive dosages and requires public health regulation. Urgent regulatory measures and strong clinical guidance are imperative to protect children’s health.

Ethical approval

This study did not require institutional ethics committee approval, as all data were compiled from publicly available sources and it did not involve any human or animal subjects.

Author contribution

The authors declare contribution to the paper as follows: Study conception and design: DO; data collection: DO, IO; analysis and interpretation of results: DO; draft manuscript preparation: DO, IO. All authors reviewed the results and approved the final version of the article.

Source of funding

The authors declare the study received no funding.

Conflict of interest

The authors declare that there is no conflict of interest.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.