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Vitamin A - Resources and Frequently Asked Questions

Vitamin A: Frequently Asked Questions - Marathi - pdf 49 kb

VITAMIN A SUPPLEMENTATION KEY MESSAGES

Significant progress has been made

Global coverage with at least one dose has climbed from 50 per cent in 1999 to 68 per cent in 2004.
The proportion of children fully protected by two doses has increased more than threefold over the same period, because countries have found opportunities to ensure two rounds of supplementation.
Vitamin A supplementation has sparked the innovative delivery of multiple interventions through child health packages. Greatest gains in the least developed countries of the world
Some of the most successful and exemplary programmes have emerged from these countries.
The least developed countries have maintained an average coverage of greater than 70 per cent with at least one dose over the period 1999-2004, often reaching more than 90 per cent of targeted children.
Opportunities exist for supplementation to be sustained through poverty reduction strategies, but advocacy is necessary to ensure continued support for vitamin A supplementation.

Acceleration needs to happen – soon!

The full child survival benefit of vitamin A supplementation is still to be realized.
Millions of children under five in the 103 priority countries are not benefiting from the full protection of vitamin A because they are not yet being reached by two rounds of supplementation.
All children in the priority countries should receive high-dose vitamin A supplements every four to six months, in addition to any doses necessary for the treatment of severe malnutrition or measles.
Supplementation of women in the post-partum period has not achieved significant gains. Opportunities are being missed to pair this intervention with an infant’s first immunization contact.

Resources

Vitamin A pills 'could save thousands of children'
27 August 2011

The WHO backs vitamin A supplementation
Giving vitamin A supplements to children under the age of five in developing countries could save 600,000 lives a year, researchers claim.

Writing in the British Medical Journal, UK and Pakistani experts assessed 43 studies involving 200,000 children, and found deaths were cut by 24% if children were given the vitamin.

Vitamin A supplements for preventing mortality, illness, and blindness in children aged under 5: systematic review and meta-analysis
(Published 25 August 2011)
Objective: To determine if vitamin A supplementation is associated with reductions in mortality and morbidity in children aged 6 months to 5 years.
Conclusions Vitamin A supplementation is associated with large reductions in mortality, morbidity, and vision problems in a range of settings, and these results cannot be explained by bias. Further placebo controlled trials of vitamin A supplementation in children between 6 and 59 months of age are not required. However, there is a need for further studies comparing different doses and delivery mechanisms (for example, fortification). Until other sources are available, vitamin A supplements should be given to all children at risk of deficiency, particularly in low and middle income countries.

Improving child survival through vitamin A supplementation
(Published 25 August 2011) [Extract] [Full text] [PDF]

Studies on malnourished children and vitamin A deficient children should also be excluded in selection of articles as these will confound the results
BMJ 28 August 2011 [Full text]

The great Vitamin A fiasco - World Nutrition - May 2010
Michael Latham
This commentary challenges the wisdom and validity of the current practice of providing to children between 6 months and 5 years, regular supplements of massive medicinal doses of vitamin A. Every year, roughly half a billion capsules are made to be distributed and to be given to around 200 million children in over 100 ‘targeted’ countries (1,2). One standard method of dosing of younger children is shown in the picture above, which appears on the cover of a United Nations Children’s Fund (UNICEF) working paper issued in 2005 (1). In most cases, this medicinal dosing is now being done in countries and areas where the vitamin A deficiency diseases xerophthalmia and blinding keratomalacia are now rare, and any clinical signs of vitamin A deficiency are now uncommon. pdf 442 kb

UNICEF: Vitamin A Supplementation - A Decade of Progresspdf 1.2 mb
This report tracks the progress of vitamin A supplementation programming following 10 years of global advocacy. It provides the most comprehensive review of efforts to date, including trends in coverage and innovations in delivering supplements. In areas of the world where vitamin A supplementation is not yet reaching all children under age five, this should serve as a call to action. For countries doing well, these findings should encourage a continued commitment to tackling hidden hunger and a desire to embark on making these programmes sustainable.

Vitamin A saves lives. Sound science, sound policy
Keith P West Jr, Rolf DW Klemm, Alfred Sommer
Vitamin A deficiency can cause blindness, impair health, and be an underlying cause of death, in young children. Therefore, responsible debate about its public health importance, and the value of prevention, should be based on reliable evidence of the extent and severity of deficiency, and on the impact of interventions. pdf 315 kb

Universal Vitamin A Supplementation Programme in India: The need for a re-look pdf 37 kb
The National Medical Journal of India - Vol. 23, No. 5, October 2010

20 Million US Dollars on Vitamin A Procurement : Out of 32 Million US Dollars of Annual Budget 2009-2010
The Indian scientists have raised their concern on over emphasis of Vitamin A supplementation to children. The recent research communications from Prof. Michael Latham and Prof. C. Gopalan have raised this issue with scientific evidence. These excerpts from the Annual Report of Micronutrients Initiatives India an International Non Government Organization, according to which out of 32 Million US Dollar available in the Annual Budget 2009-2010, more than 20 Million US Dollars were spent on Vitamin A Procurement and Interventions. A meager sum of 2.5 Million US Dollars were spent on Iron interventions.

Anaemia is most common nutritional deficiency disorders in the country. Almost vulnerable age groups have anaemia in the range of 60-90%. The health consequences of anaemia are highly detrimental to Maternal and Child Health. The prevalence of Vitamin A deficiency is less than one percent and is limited to selected geographical pockets in the country. The Keratomalacia and Nutritional Blindness have disappeared.

It is unfortunate but true that the agencies are trying to implement interventions for prevention and control of micronutrients disorders according to their mandate rather than the magnitude and health consequences.

Research Methods & Reporting:
The impact of outcome reporting bias in randomised controlled trials on a cohort of systematic reviews
BMJ (Published 15 February 2010)
[Abstract] [Full text] [PDF] [Web Extra]

Education and debate:
Grading quality of evidence and strength of recommendations
BMJ (Published 17 June 2004)
[Abstract] [Full text] [PDF] [Abridged PDF]

Education and debate:
Measuring inconsistency in meta-analyses
BMJ (Published 4 September 2003)
[Extract] [Full text] [PDF]

Paper:
Simultaneous zinc and vitamin A supplementation in Bangladeshi children: randomised double blind controlled trial
BMJ (Published 11 August 2001)
[Abstract] [Full text] [PDF]

Editorial:
Trials: the next 50 years: Large scale randomised evidence of moderate benefits
BMJ (Published 31 October 1998)
[Extract] [Full text] [PDF]

Research Article:
Vitamin A supplementation in infectious diseases: a meta-analysis.
BMJ (Published 6 February 1993)
[Abstract] [PDF]

Research Article:
Childhood mortality after a high dose of vitamin A in a high risk population.
BMJ (Published 25 January 1992)
[Abstract] [PDF]

UNICEF, Maharashtra, India - Frequently Asked Questions

Q1. What is Vitamin A?

A1. Vitamin A (VA) is a fat-soluble vitamin 'that is required by our body. It cannot be synthesised by the body, thus consumption through food is necessary.

It occurs in two forms in nature: plant form (as β-Carotene) and animal form (as Retinol). Plan sources contain beta- carotene, more natural form of VA. Beta-carotene has to be converted into VA in the body in order to be used by it. Fat and bile (secreted by the gall bladder) are needed for the conversion.

Q2. For whom Vitamin A (VA) is the most essential?

A2. VA is essential to everyone. However, it is the most essential for infants and young children and pregnant and lactating women.

Q3. What are the benefits of Vitamin A?

A3. Vitamin A protects children against nutritional blindness and is essential for the functioning of the immune system i.e. it enhances children's disease resistance capacity and protects against illness/morbidity, and reduces deaths/mortality. Therefore, it is essential for child survival.

Preventing Vitamin A deficiency (VAD) in pregnant women reduces chances of maternal morbidity and mortality.

Q4. What is Vitamin A deficiency (VAD) and how can it be recognised?

A4. VAD means that the body's store of Vitamin A has decreased/depleted. Children suffering from VAD are more likely to be sick and severe VAD can cause blindness in children. Severe VAD increases the chances of children dying.

VAD can be both clinical and sub-clinical. Clinical VAD is apparent from history or clinical examination whereas sub-clinical VAD can be detected from low retinol levels in the blood by conducting a laboratory test.

Q5. Who can suffer from Vitamin A deficiency (VAD) and what causes it?

A5. VAD can affect anyone although infants and young children (especially when III); pregnant and lactating women are more likely to suffer from it. The primary cause is insufficient intake of Vitamin A rich foods and inappropriate breastfeeding either due to poverty or inadequate knowledge about nutrition. Infections, such as measles and diarrhea can precipitate clinical VAD in children.

Q6. What is the relationship between measles and VAD?

A6. Both measles and VAD adversely affect the body's defense mechanism against infections thereby increasing vulnerability to other infections. This further depletes the already limited Vitamin A stores in the body. The probability of a malnourished child with measles developing blindness due to VAD is much higher. Research indicates that Vitamin A supplements reduce death due to measles by 50%.

Q7. When is Vitamin A Deficiency considered as a public health problem?

A7 According to WHO/IVACG if in any area, 1% of children suffer from night blindness or 0.5% children have visible signs of VAD such as Bitot's spot or 5/% pregnant women suffer from night blindness, then VAD is defined as a public health problem in that area.

WHO guidelines (in the absence of data on clinical VAD signs) suggests that Under 5 Mortality Rate (U5MR) of 70 or more could be taken as an indicator of likely Vitamin A deficiency problem.

Q8. What happens if a child is Vitamin A deficient?

A8. VAD increases the risk of disease and death from severe infections such as measles and diarrhoea. In young children VAD can also cause growth retardation. VAD affects many tissues in the body; however its effect is most apparent on the eye. Children with clinical VAD face difficulty in seeing in the night, termed as 'night blindness'. At a more severe stage, it results in Bitot's spots, Corneal Xerosis/ ulceration, Keratomalacia and Corneal scar.

Pictures of V AD signs with explanation.

Q9. What happens if a pregnant or lactating women is Vitamin A deficient?

A9. In pregnant women, VAD causes night blindness and is likely to increase the risk of maternal mortality. Also, pregnant women with VAD are 3 times more likely to be anaemic.

VAD in lactating .women results in lower level of Vitamin A in colostrum and breast milk. As a result, the infant or young child on breast milk may not receive adequate Vitamin A, which in turn results in lower Vitamin A stores in their body.

Q10. Can Vitamin A deficiency be cured?

A10. All the Vitamin A Deficiencies can be cured. The scar of Bitot's spot may take sometime to clear and even if it remains, it does not affect the vision. However, scar of the corneal ulcer may persist even after cure. Therefore they have to be prevented early in life. Moreover early intervention is critical for survival of the child.

Q11. How can Vitamin A deficiency be prevented in children?

A11. VAD is the leading cause of preventable blindness in children. VAD can be prevented in children by

Early initiation of breast feeding i.e. breast feeding within an hour of delivery and continued feeding of colostrum,
Exclusive breast feeding for the first 6 months,
Introducing complementary food to 6 month old children. These foods should include Vitamin A rich foods,
Continued breast feeding till the child is 2 year' old, and
Providing children in the age group of 9-36 months with Vitamin A supplementation at 6 monthly intervals.
Preventing illness such as diarrhoea, measles and ARI; and round worm infestation. Ensuring proper management of illness in case of an infant or young child suffering from these.

Q12. From where do we get Vitamin A?

A12. Our body cannot make Vitamin A though it can store extra VA when consumed so that it is available in time of need.

For infants and young children, the best source of Vitamin A is breast. milk including colostrum (yellow milk secreted for the first 5 days). For young children, pregnant and lactating women, there are two other VA rich dietary sources - plant and animal foods.

Q13. What are the plant sources of Vitamin A?

A13. The plant sources include - green leafy vegetables and yellow/orange fruits and vegetables especially carrot, papaya, pumpkin, mango, oranges etc. Red palm oil is also rich in Vitamin A.

Ghee/oil/butter should be added to these vegetables for better conversion of β-Carotene to VA.

Photo of fruit and vegetables

Q14. What are the animal sources of Vitamin A?

A14. The animal sources include - liver, egg, fish, milk and milk products such as cheese, curd and butter.
Photo of animal sources

Q15. What is the daily recommended intake of Vitamin A?

A15. National Institute of Nutrition (NIN) recommends 600-950 micrograms (μg) of Vitamin A (Retinol) for adults per day - 600 μg for males and pregnant as well as non-pregnant females, and 950 μg during lactation. Thus, mother's intake of VA should be higher during breastfeeding as breast milk is the source of Vitamin A for the baby.

Infants require 350 μg and children in the age group of 1-3 years require 400 mg of Vitamin A per day. This implies 1 tablespoon of cooked green leafy vegetable per day for a young child, 2 tablespoons of cooked green leafy vegetable per day for pregnant woman and 3 tablespoons of green leafy vegetable per day for a lactating mother.

Q16. Is Vitamin A supplementation (VAS) necessary and why?

A16. Yes, VAS is necessary. The continued prevalence of Vitamin A deficiency in children in parts of the country necessitates the need for VA supplementation. Although intake of VA rich foods is essentials and is a long term goal, in the short run, VA supplementation is cost effective and a proven means (efficacy and easy applicability) to increase the VA status of children.

Four primary reasons for the need for VAS are:

Non-availability of VA rich foods,
Non-accessibility to VA rich foods
Recurrent illness, and
Extended illness.

In many areas it is difficult to grow V A rich foods because of the poor terrain and lack of facilities. On the other hand, in areas where VA rich food is available, it may not be accessible to certain communities/ families/ individuals. Also, inadequate hygienic conditions and poor management of illness result in depletion of VA stored in the liver. Therefore, VA supplementation becomes necessary to make VA available to the body and increase the Vitamin A stores and thus prevent VAD and its consequences.

Photo of Bottle of VA solution + spoon

Q17. At what age should children be given Vitamin A supplementation?

A17. A prophylactic (preventive) dose of Vitamin A supplementation should be given to all children in the age group of 9-36 months at 6 monthly intervals. However, children between 3-5 years can also be given Vitamin A supplementation at 6 monthly intervals. Ideally, a child should have received the complete 5 doses of VA by the age of 3 years.

Q18. What is the prophylactic dose to be given to these children?

A18.

At a time: Children in the age group of 9-12 months should be given 1 mi. (100,000 IU) i.e. half a spoon of VA solution (the spoon accompanies the solution bottle).
Children in the age group of 12-36 or 12-60 months should be given 2 mi. (200,000 IU) i.e. one spoon full of Vitamin A solution.
Photo of A spoon half filled and completely filled with Vitamin A.

Q19. How often should VAS be given?

A19. VAS should be given at 6 monthly intervals. Once VAS is given, VA gets stored in the liver and is used by the body from there. This mega dose (1 ml or 2 ml as based on the age of the child) needs replacement after 4-6 months as the dietary source is usually not adequate to maintain the VA level in the body.

Q20. Is the VA solution dosage safe for children?

A20. When administered in recommended doses i.e. 1 ml for children between 9-12 months and 2 ml. for children above 1 year, it is effective and safe. Adverse effects are rare, mild and transient. Experience across the world shows that 0.5- 7% of children given VAS can suffer from adverse effects that are transient i.e. they disappear within 24-48 hours. These symptoms include headache, loose stool and vomiting. These are mild and transitory and do not require any treatment.

Q21. Can Vitamin A solution be given to pregnant/lactating women?

A21. The high dose of VA solution available should not be given to pregnant/lactating women. But pregnant/lactating women suffering from night blindness should be referred to the Doctor or Auxiliary Nurse Midwife (ANM) for appropriate treatment.

Q22. What are the storage conditions of VA solution and does it have a shelf life?

A22. Vitamin A. solution should be kept away from sunlight in a cold dark place (this does not mean keeping in a refrigerator). It should be kept out of reach of children.

A sealed bottle can be kept at room temperature for 1 year. However, once opened, the bottle of Vitamin A should be used within 6-8 weeks and if not, it should be thrown away.

Q23. Can VA solution be given to a child who is ill?

A23. VA solution should not be given at home to a child suffering from any serious illness like uncontrolled vomiting, severe diarrhoea, and child ill enough to require hospitalisation.

Under such conditions, the child should be referred to the Doctor or ANM for appropriate medical care.

Q24. Is there a therapeutic dose of VA for children?

A24. Yes, there are therapeutic doses of VA solution. These should be administered only by the Doctor or ANM

All children with Xerophthalmia should be given 2 doses of Vitamin A.
All children suffering from measles should be given 1 dose of Vitamin A (if not received in the previous month).
All children with Protein-Energy Malnutrition (based on weight for age criteria or clinical malnutrition signs) should be given 1 additional dose of Vitamin A.
Children suffering from persistent diarrhoea (diarrhoea for 14 days or more) should be given 1 dose of VA.
No additional dose is to be given to children suffering from acute diarrhoea or ARl.

Q25. Is the VA supplementation programme, a national programme?

A25. Yes, National Prophylaxis Programme for Prevention of Blindness due to Vitamin A Deficiency is a national programme. It includes variety of foods including VA rich foods, breast feeding including colostrum feeding along with VAS. It supports VAS primarily through the routine system.

The first dose (1 ml or half spoon) is given with routine measles immunisation (9 months),
The second dose (2 ml or full spoon) is given with first DPT /OPV booster (16-18 months) and
The next three doses (each dose of 2 ml or full spoon) are given after every 6 months.

Other than the routine supplementation, the need for bi-annual special effort especially in areas with low coverage is recognised as an approach to increase V AS coverage along with other key child health and nutrition interventions.

The programme is implemented by collaborative effort of functionaries from Health and ICDS departments.

Q26. Where is Vitamin A solution available?

A26. Vitamin A solution is available in all the health sub-centres. It is the responsibility of ANM to administer Vitamin A solution as per the schedule mentioned under the national programme. Anganwadi Worker (AWW) also helps the ANM in carrying out this activity.