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Resources and Frequently Asked Questions
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.
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.
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]
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
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)
Education and debate:
Grading quality of evidence and strength of recommendations
BMJ (Published 17 June 2004)
Education and debate:
Measuring inconsistency in meta-analyses
BMJ (Published 4 September 2003)
Simultaneous zinc and vitamin A supplementation in Bangladeshi children:
randomised double blind controlled trial
BMJ (Published 11 August 2001)
Trials: the next 50 years: Large scale randomised evidence of moderate benefits
BMJ (Published 31 October 1998)
Vitamin A supplementation in infectious diseases: a meta-analysis.
BMJ (Published 6 February 1993)
Childhood mortality after a high dose of vitamin A in a high risk
BMJ (Published 25 January 1992)
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
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
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
Q7. When is Vitamin A Deficiency considered as a public
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
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
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
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
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
- 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
Q21. Can Vitamin A solution be given to
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
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
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
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.