Vitamin A supplementation in infants and children 6–59 months of age

WHO recommendations Guidance summary*

In settings where vitamin A deficiency is a public health problem** (prevalence of night blindness is 1% or higher in children 24–59 months of age or where the prevalence of vitamin A deficiency (serum retinol 0.70 µmol/l or lower) is 20% or higher in infants and children 6–59 months of age), high-dose vitamin A supplementation is recommended in infants and children 6–59 months of age.

Suggested vitamin A supplementation scheme for infants children 6–59 months of age:

Target group                  —  Infants 6–11 months of age (including HIV+)   —  Children 12–59 months of age (including HIV+)

Dose                              —  100 000 IU (30 mg RE) vitamin A                        —  200 000 IU (60 mg RE) vitamin A

Frequency                     —  Once                                                                    —  Every 4-6 months

Route of administration —  Oral liquid, oil-based preparation of retinyl palmitate or retinyl acetate

Settings                           —  Populations where the prevalence of night blindness is 1% or higher in children 24–59 months of age or where the prevalence of vitamin A deficiency (serum retinol 0.70 μmol/l or lower) is 20% or higher in infants and children 6–59 months of age.

IU, international units; RE, retinol equivalent. a. An oil-based vitamin A solution can be delivered using soft gelatin capsules, as a single-dose dispenser or a graduated spoon (2). The consensus among manufacturers to use consistent color coding for the different doses in soft gelatin capsules, namely red for the 200 000 IU capsules and blue for the 100 000 IU capsules, has led to much-improved training and operational efficiencies in the field.

Remarks

  • This guideline replaces previous recommendations on vitamin A supplementation for the prevention of vitamin A deficiency, xerophthalmia, and nutritional blindness in infants and children 6–59 months of age (3).
  • The above recommendation can also be applied in populations where infants and children may be infected with HIV.
  • The magnitude of the effect may differ across settings and populations, possibly due to the extent of vitamin A deficiency or the availability of other nutrients (e.g. dietary intake of vitamin A will differ across locations and the effects of supplementation may be smaller in places with greater access to vitamin A-rich foods or with regular consumption of vitamin A-fortified foods).
  • This intervention should be used along with other strategies to improve vitamin A intakes, such as dietary diversification (4) and food fortification (5).
  • Adverse effects within 48 hours of receiving supplements containing 100 000–200 000 IU vitamin A are usually mild and transient, with no longterm consequences. Adverse effects may include bulging of open fontanelles in younger infants, and nausea and/or vomiting and headache in older children with closed fontanelles.
  • Vitamin A supplements should be delivered to children 6–59 months of age twice yearly, during health system contacts. This should be marked on the child health card, or integrated into other public health programmes aimed at improving child survival, such as polio or measles national immunization days, or biannual child health days delivering a package of interventions such as deworming, distribution of insecticide-treated mosquito nets and immunizations.
  • A quality assurance process should be established to guarantee that supplements are manufactured, packaged and stored in a controlled and uncontaminated environment (6).
  • When determining the vitamin A status of a population, guidelines on indicators for assessing vitamin A deficiency should be referred to (7, 8).
  • Recommendations for the treatment of xerophthalmia and the use of vitamin A supplements during episodes of measles are not covered in this guideline. Existing guidelines on the treatment of xerophthalmia and measles in infants and children 6–59 months of age should be referred to in these cases (3, 9).

* This is an extract from the relevant guideline (10). Additional guidance information can be found in this document.

** Determination of vitamin A deficiency as a public health problem involves estimating the prevalence of deficiency in a population by using specific biochemical and clinical indicators of vitamin A status. Classification of countries based on the most recent estimates is available in the guidance document, Global prevalence of vitamin A deficiency in populations at risk 1995–2005 (1).

Case Study – UNICEF INDIA

Vitamin A supplementation: a national good news story

Record coverage attained, with 62 million under-fives protected from vitamin A deficiency in just one year

The World Health Organization (WHO) recommends that in vitamin A-deficient areas, children six months to five years should receive a preventive dose of vitamin A supplementation every six months. While India’s vitamin A program follows this recommendation, a 2006 National Family Health Survey indicated that only 25 percent of under-fives were receiving supplementation. Further analysis showed children missed by the program would benefit greatly, as they were more likely to be undernourished and belong to vulnerable families. The study also showed states with higher under-five mortality rates had lower vitamin A supplementation coverage.

Recognizing the problem, the government that same year adopted biannual supplementation to reach out to children under-five with the following regime:

  • Children below one year receive the first vitamin A supplementation dose with their routine measles immunization at nine months.
  • For children aged one to five years, the subsequent nine doses of vitamin A supplementation be administered twice a year, six months apart, through a biannual large-scale outreach vitamin A supplementation strategy.

Currently, 15 of India’s major states are taking part in this biannual outreach strategy in partnership with UNICEF and others. UNICEF’s role has been to support state governments’ capacities to source and distribute vitamin A supplements to districts and blocks on time while mobilizing families and communities to bring their children to take advantage of the scheme.

As a result of the program, the proportion of children receiving two doses of vitamin A annually – referred to as “full vitamin A supplementation coverage” – increased from a quarter in 2006 to two-thirds in 2011, with seven of India’s 15 major states reporting full coverage rates of more than 80 percent. In 2011 alone, a record 62 million children were protected. Importantly, between 2007 and 2011.

Refer below documents for more information: