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Letters to the Editor

Indian Pediatrics 2003; 40:584

Reduction in Prevalence of Bitot's Spots after Administration of Mega-Dose of Vitamin A


 

The most common indicator used for estimating vitamin A deficiency (VAD) in a community is Bitot’s Spot (BS). Bitot’s spot is a white, foamy, cheesy, thickened, superficial layer of sloughed, flattened cells containing a desquamated keratinized surface, a prominent granular cell layer and complete absence of goblet cells(1). VAD is regarded as a public health problem in a community if the prevalence of Bitot’s spots amongst under 6 years children is 0.5% or more(2). In a vitamin A (VA) deficient community, adminis- tration of mega-dose of vitamin A is recommended. The schedule for the oral prophylactic dose of vitamin A is one dose of 1,00,000 IU to infants in age group of 6-11 months and six monthly doses of 2,00,000 IU to children in the age group of 12-36 months(3). The impact of VA supplemen-tation on VAD status in a community is re-assessed by studying the prevalence of Bitot’s spots in children under 6 years of age. There are conflicting reports on the duration after which Bitot’s spots disappear and percentage of Bitot’s spots that disappear after administration of mega dose of vitamin A in scientific literature.

Community based studies on reduction in prevalence of Bitot’s spots after vitamin A administration amongst preschoolers have been reported. A study from Bangladesh(4) reported a progressive decrease in prevalence of Bitot’s spots to less than 0.5% after vitamin A supplementation (Table I). However, in studies from Nepal and Indonesia, the prevalence of Bitot’s spots continued to indicate that VAD was a public health problem in the population despite a decline after mega dose of vitamin A(5,6) (Table I).

Table I

Impact of Administration of Massive Dose of (2,00,000 I.U.) Vitamin A on the Reduction in
Prevalence of Bitot’s Spots in Children.
	
  Country Age
group
(Years)
Sample Frequency
of dose
   Prevalence of BS
Base Line     Follow up 
Community based studies
Bangladesh
1981(4)
1-5
12494
single dose
0.5%
0.42% (3 months)
0.24% (6 months)
0.15% (9 months)
 
Nepal
1980-81(5)
1-5
1326
single dose
3.37%
2.24%(6 months)
 
Indonesia
1975(6)
1-6
1197
every 6 months
4.7%
3.37% (6 months)
Controlled logitudinal
studies
Indonesia
1990(7)
3-6
88
single dose
100%
6.8% (5 weeks)
 
Indonesia
1982(8)
<5
48
single dose
100%
0% (3-4 months)
0% (5-6 months)
 
India
1976(9)
<5
25
every 4 months
100%
68%(12 months)
The numbers in parentheses indicate duration of follow up.

 

Controlled longitudinal studies have been conducted in preschool children with Bitot’s spots. Results from Indonesia revealed that after five weeks, there was a 93.2% reduction in prevalence of Bitot’s spots after receipt of mega dose of vitamin A(7). Similarly, a vitamin A supplementation trial on 48 preschoolers with Bitot’s spots showed that all BS disappeared after 3 months(8). However, a four monthly vitamin A supplementation in preschoolers with Bitot’s spots done in India reported that after one year of supple-mentation with mega doses of vitamin A, the prevalence of Bitot’s spots was reduced by only 32%(9) (Table I).

Seasonal variation in prevalence of Bitot’s spots has been documented in community based studies with the peak prevalence observed in May-June(10). In disadvantaged and resource poor communities the Bitot’s spots may disappear in children after administration of vitamin A; however a possibility of appearance of Bitot’s spots in new subjects exists(11-13). Persistent Bitot’s spots which could be due to other reasons and do not respond to mega dose of vitamin A administration are known to occur in the community. The etiology of these persistent Bitot’s spots is not clearly under-stood(1,14,15).

The existing scientific data reveals that Bitot’s spots prevalence decrease after administration of mega doses of Vitamin A, but within how much duration the prevalence comes down to less than 0.5% is not exactly known. Hence, the re-survey data on impact of megadose of vitamin A administration on prevalence of Bitot’s spots should be carefully interpreted. There is a need to undertake longitudinal studies on this issue.

Vani Sethi,
Umesh Kapil,

Department of Human Nutrition,
All India Institute of Medical Sciences,
New Delhi 110 029, India.
E-mail: [email protected]

REFERENCES


1. Sommer A. Conjuctival Appearance in corneal xerophthalmia. Arch Ophthalmol 1982; 100: 951-952.

2. World Health Organization. 1996. Indicators for Assessing Vitamin A Deficiency and their Application in Monitoring and Evaluation Intervention Programme. WHO, Geneva, 1996, pp 5-14.

3. Kapil U, Sachdev HPS. National Consultation of Benefits and Safety of Administration of Vitamin A to Pre-school children and Pregnant and Lactating Women. Indian Pediatr 2001; 38: 37-42.

4. Jalil MA. Vitamin A deficiency prevention program in Bangladesh. In: Report of the International Vitamin A Consultant Group Annual Meeting, Nairobi, Kenya, November 9-11, 1981.

5. Upadhyaya MP, Pillai KK, Gurung BJ, Nepal BP. Xerophthalmia in Nepal 1980-81, His Majesty’s Government of Nepal, undated.

6. Tarwojo I, Ten DJ, Gunawan S, Reddy S, Sullivan EH. An Evaluation of Vitamin A Deficiency Prevention Pilot Project in Indonesia, New York, NY: The Ministry of Health, Government of Indonesia and the American Foundation for Overseas Blind, 1976.

7. Semba RD, Wirasamita S, Natadisastra G, Muhilal, Sommer A. Response of Bitot’s spots in preschool children to vitamin A treatment. Am J Ophthalmol 1990; 110: 416-420.

8. Sommer A, West KP. Xerophthalmia and Keratomalacia. In: Vitamin A deficiency: Health, Survival and Vision. New York, Oxford University Press, 1996; pp 100-116.

9. Sinha DP, Bang FB. The effect of massive dose of vitamin A deficiency in preschool children. AM J Clin Nutr 1976; 29: 110-115.

10. Sinha DP, Bang FB. Seasonal variation in signs of vitamin A deficiency in rural West Bengal children. Lancet 1973; 2: 228-230.

11. Reddy V, Bhaskaran P, Radhumulu N, Milton RC, Rao V, Madhusudan J et al. Relationship between measles, malnutrition and blindness: A prospective study in Indian children. Am J Clin Nutr 1986; 44: 924-930.

12. Stephenson CB, Alvarez JO, Kohatsu J, Hardemeier R, Kennedy JI Jr, Gammon RB Jr. Vitamin A is excreted in the urine during acute infection. Am J Clin Nutr 1994; 60: 388-392.

13. Bhaskaran P, Reddy V, Raj S, Bhatnagar RC. Effect of measles on the nutritional status of preschool children. J Trop Med Hyg 1984; 87: 21-25.

14. Sommer A, Emran N, Tjakrasudjatma S. Clinical characteristics of vitamin A responsive and non-responsive Bitot’s spots. Am J Ophthalmol 1980; 90: 160-171.

15. Sommer A, Green WR, Kenyon KR. Bitot’s spots responsive and non-responsive to vitamin A: Clinicopathologic correlations. Arch Ophthalmol 1981; 99: 2014-2027.

 

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