September 2024 OTC Case Studies: Vitamins

CASE 1: Fluoride

SF is a boy aged 6 years who visits the pharmacy with his father. His father informs the pharmacist that they have recently moved to the area and discovered that the community’s water is fluoridated at 0.5 ppm. Concerned that SF might not receive enough fluoride, his parents are seeking an OTC fluoride supplement.

Q: What should the pharmacist recommend to SF and his father?

A: The pharmacist should inform SF’s father that children aged 3 to 6 years require fluoride supplementation of 0.25 mg/d if the fluoride level in drinking water is between 0.3 and 0.6 ppm. SF’s father can ensure SF gets the recommended fluoride by using pea-sized amounts of OTC fluoride toothpaste. If SF can swish and spit, he may use OTC fluoride rinses, especially if he is at high risk for dental caries. SF’s father should consult their pediatrician before starting SF on dietary fluoride supplements, which are available OTC in liquid or tablet form. The fluoride from toothpaste is typically sufficient. Significantly, excess fluoride can increase the risk of fluorosis, a condition that occurs from excessive fluoride intake during the years when teeth are developing. It can cause changes in the appearance of the tooth enamel, ranging from mild discoloration to more severe staining and pitting. Additionally, fluoride is found in juices, carbonated beverages, and many processed foods.¹

CASE 2: Zinc

CN is an infant aged 7 months who is brought to the pharmacy by her mother after a visit to the pediatrician. The pediatrician recommended increasing the amount of zinc in CN’s diet due to her age and exclusive breastfeeding since birth. CN’s mother is seeking information about the role of zinc and the daily requirement for her baby.

Q: What counseling points and recommendations should the pharmacist provide?

A: The pharmacist should counsel CN’s mother that zinc levels are initially high in breast milk after birth but decline over the first 6 months of lactation and are unaffected by maternal zinc intake.² Therefore, it is essential to introduce zincrich foods, such as zinc-fortified infant cereals, meats, beans, and dairy, into a child’s diet after 6 months to facilitate growth and immune function.² The Dietary Guidelines for Americans state that the recommended daily allowance for children aged 6 to 11 months is 3 mg/d.2 CN’s mother should also be counseled that OTC products, such as oral drops, are available to help supplement CN’s diet to achieve the recommended amount. However, it is important to avoid excessive zinc intake because it can lead to adverse effects such as nausea, vomiting, loss of appetite, abdominal cramps, diarrhea, and headaches. Excessive zinc can also interfere with the absorption of other essential minerals, such as copper and iron.²

CASE 3: Iron in Preterm Infants

JL, a newborn aged 2 weeks, is brought to the pharmacy by his mother. She shares that JL was born prematurely at 32 weeks’ gestation and has been exclusively breastfed since birth. JL’s pediatrician advised starting him on an iron supplement, but his mother is unsure about the appropriate product and dosage.

Q: What recommendations should the pharmacist provide to JL and his mother?

A: The pharmacist should inform JL’s mother that iron accumulation during pregnancy primarily occurs during the third trimester. Consequently, premature infants are more prone to iron deficiency. The American Academy of Pediatrics recommends that infants born before 37 weeks’ gestation who are breastfed should receive 2 mg/kg per day of elemental iron from 1 month through 12 months of age to prevent iron deficiency. The pharmacist can suggest OTC supplements such as iron drops to JL’s mother; these can be easily administered starting at the age of 1 month.³

CASE 4: Multivitamins

AG is a girl aged 9 years who was brought to the pharmacy by her father. AG’s father tells the pharmacist that he is interested in starting AG on a vitamin C supplement because it is almost September, and he is worried that AG may get easily sick once the school year begins. He wishes to boost her immune system against common infections. He also informs the pharmacist that he is concerned that AG is not getting enough vitamin C in her diet because she is a fussy eater who does not enjoy fruits and vegetables.

Q: What should the pharmacist recommend to AG and her father?

A: The pharmacist should counsel AG’s father that vitamin C is essential to immune function.4 The recommended daily allowance of vitamin C in girls between the ages of 9 and 13 years is 45 mg/d.2 Fruits and vegetables, such as citrus fruits, tomatoes, and potatoes, are the best sources of vitamin C.4 Because AG does not consume these types of foods frequently, she may require vitamin C supplementation to achieve the recommended amount through OTC products, which are available in chewable and liquid drop formulations that may be preferable for children.

REFERENCES

1. Clark MB, Keels MA, Slayton RL; Section on Oral Health. Fluoride use in caries prevention in the primary care setting. Pediatrics. 2020;146(6):e2020034637. doi:10.1542/peds.2020-034637

2. US Department of Agriculture and US Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th edition. December 2020. Accessed August 12, 2024. https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf

3. Baker RD, Greer FR; Committee on Nutrition American Academy of Pediatrics. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Pediatrics. 2010;126(5):1040-1050. doi:10.1542/peds.2010-2576

4. Vitamin C fact sheet for health professionals. National Institutes of Health Office of Dietary Supplements. Updated March 26, 2021. Accessed August 12, 2024. https://ods.od.nih.gov/factsheets/VitaminC-HealthProfessional/