Indian Pediatrics 2001; 38: 37-42
Consultation on Benefits and Safety of Administration of Vitamin
1. Issue: National Program for Prophylaxis Against Blindness in Children Caused Due to Vitamin A Deficiency (VAD): Past and Present Status and Changing Profile of VAD and its Current Status.
1.1 Conclusions of the Discussions on Scientific Presentations
1.1.1. In India, the magnitude of clinical VAD has declined significantly but exists as a public health problem in scattered pockets.
1.1.2. The problem of clinical VAD varies from cluster to cluster within selected districts.
1.1.3. There is a need for a careful evalua-tion of the current profile of clinical VAD and the reasons for change in VAD profile in the country.
1.2 Specific Recommendations
1.2.1. The existing data on VAD should be analyzed by independent groups of Epidemiologists, Statisticians, Nutritionists, Pediatricians, Ophthalmologists and Obstetricians to assess the current status of VAD.
1.2.2. The National Program for Prophylaxis against Blindness in Children Caused Due to Vitamin A Deficiency requires re-examination and the time has come that VAD control should be a part of the primary health care.
1.2.3. The National Program for Prophylaxis against Blindness in Children Caused Due to Vitamin A Deficiency should clearly define the quantifiable outcomes of implementation of the program.
1.2.4. Since, multiple nutritional problems co-exist in the same population, while executing any program to control them, a holistic approach should be adopted for combating nutritional deficiencies and vertical approach aimed at single nutrient should be discouraged.
2. Issue: Administration of Synthetic Vitamin A to Pregnant and Lactating Women
2.1 Conclusions of the Discussions on Scientific Presentations
2.1.1. Pregnant and lactating women should be encouraged to improve their overall nutrition. Principles of consuming balanced diet with diversification in food items are necessary to maintain adequate macro and micro-nutrient status.
2.2. Specific Recommendations
2.2.1. As part of comprehensive antenatal and postnatal care, women should be screened for night blindness. If pregnant/lactating women have night blindness, they should be referred to the physician in the nearby Primary Health Center or any other health facility for appropriate management. In view of the poten-tial toxic and teratogenic effects of high doses of vitamin A, pregnant and lactating women with symptoms of night blindness should be treated with vitamin A in dosage not exceed-ing 10,000 IU per day. They can be given vitamin A till symptoms of night blindness disappear.
2.2.2. For sustainable elimination of VAD, production and consumption of vitamin A rich foods must be strongly promoted in the community, particularly amongst pregnant and lactating women and children.
3. Issue: Administration of synthetic vitamin A to children between 6-60 months.
3.1. Conclusions of the Discussions on Scientific Presentations
It should be recognized that the National Program for Prophylaxis Against Blindness in Children Caused Due to Vitamin A Deficiency was initiated in the country primarily to prevent blindness due to vitamin A deficiency in young children and not to control childhood mortality.
3.1.1. Overall improvement in nutritional status of children is essential to reduce under five mortality and morbidity. This includes promotion of breastfeeding, appropriate complementary feeding, strategies to reduce LBW babies and prompt treatment of child-hood illnesses.
3.1.2. Administration of Vitamin A with measles or polio vaccines does not interfere with their seroconversion rates.
3.2 Specific Recommendations
3.2.1. Available data are not robust enough to persuade us to recommend a policy of vitamin A supplementation for the purpose of mortality reduction in children.
3.2.2. The current program recommenda-tions of periodic administration of vitamin A, starting with measles vaccine at 9 months till 3 years of age should be persisted with.
3.2.3. To achieve optimal benefit of the National Program for Prophylaxis against Blindness in Children Caused Due to Vitamin A Deficiency, high coverage (>90%) of the target population must be ensured (at least for first 2 doses of vitamin A).
3.2.4. Strengthening of routine immuniza-tion including measles vaccination will be an additional step to improve vitamin A nutrition.
3.2.5. Screening for clinical symptoms and signs of VAD in children should become a part of primary health care. All children with clinical VAD are to be treated as per the standard schedule of Government of India under RCH program.
A suggestion was made that an "Expert Committee on Vitamin A" of Epidemiologists, Statisticians, Nutritionists, Pediatricians, Ophthalmologists and Obstetricians may be constituted to critically review and re-analyze the complete data available from published studies/trials conducted in India and abroad on the issues raised in this consultation. This would help in giving future direction/ strategy to be adopted for implementation of National Program for Prophylaxis against Blindness in Children Caused Due to Vitamin A Deficiency.
4. Issue: Linking of Synthetic Vitamin A Administration with Pulse Polio Immunization
4.1. Conclusions of the Discussions on Scientific Presentations
4.1.1. Linking of vitamin A with Pulse Polio Immunization (PPI) provided different experi-ences in the states of Orissa and Uttar Pradesh (UP). In Orissa where the operation was backed by the support of UNICEF and WHO, and the staff gained the experience of administering vitamin A through an earlier round of campaign approach, the coverage rates were high. In UP, where the vitamin A administration was linked to PPI without similar support or prior experience, the coverage rates were poor.
4.1.2. In Orissa, risk of immediate side effects attributable to vitamin A administration, such as fever, nausea and vomiting, was similar in children who received vitamin A with oral polio vaccine and those who did not (about 3%). However, unequivocal evidence does not exist on possible long-term consequences of increased intracranial pressure (presenting as bulging fontanel).
4.1.3. Linking of vitamin A administration to PPI should be avoided at this juncture when the country is on the verge of achieving zero incidence of polio, in view of the absence of information on the long-term consequences of vitamin A administration to young child-ren, inconsistent coverage rates and the enormity of training requirements. Instead, streng-thening the vitamin A coverage under the existing National Program for Prophylaxis Against Blindness in Children Caused Due to Vitamin A Deficiency, was considered appropriate.
4.1.4. Taking cognizance of the fact that in some states ocular manifestations of vitamin A deficiency are above the level of public health significance, it was suggested that alternative strategies should be explored for improving vitamin A coverage instead of linking vitamin A distribution with PPI.
4.2 Specific Recommendations
4.2.1. Synthetic vitamin A supplementation should not be linked to PPI.
4.2.2. In areas where vitamin A deficiency manifestations are high, alternative approaches may be explored for improving vitamin A coverage instead of linking vitamin A distribution with PPI.
5. Issue: Therapeutic Administration of Synthetic Vitamin A during Measles, Severe Protein Energy Malnutrition, Xerophthalmia and Diarrheal Diseases
5.1. Specific Recommendations
5.1.1. All children with xerophthalmia should be given two doses of synthetic vitamin A as per present schedule of Government of India under RCH program.
5.1.2. All children suffering from measles should also be given one dose of vitamin A, if he/she has not received it during the previous one month.
5.1.3. All cases of severe Protein Energy Malnutrition (based on weight for age criteria or clinical nutritional signs) should be given one additional dose of vitamin A.
5.1.4. No additional dose of vitamin A is required for children suffering from diarrhea and respiratory tract infections.
Compiled by: Dr. Umesh Kapil, Additional Professor, Department of Human Nutrition, All India Institute of Medical Sciences, New Delhi 110 029, India and Dr. H.P.S. Sachdev, Professor and Incharge, Division of Clinical Epidemiology, Department of Pediatrics, Maulana Azad Medical College, New Delhi 110 002, India.
Correspondence to: Dr. Umesh Kapil, Additional Professor, Department of Human Nutrition, A.I.I.M.S., New Delhi 110 029, India. E-mail: firstname.lastname@example.org
List of Participants
Representatives from Indian Council of Medical Research
Representatives from the Government of India and State Governments
Representatives from International and Bilateral Agencies