National vitamin a prophylaxis programme : Need for change in current age strategy

Child survival and Safe Motherhood Programme emphasises on giving vitamin A prophylaxis upto three years of age only, contrary to earlier practice of its administration upto six years of age, based on the assumption of reduction of serious manifestations of vitamin A deficiency three years of age onwards. A cross-sectional study enrolling 1094 children was done to investigate vitamin A deficiency in under six children in urban slums of Nagpur city in Central India in post CSSM scenario. Clinical as well as subclinical (detected by abnormal conjunctival impression cytology) assessment of vitamin A status was performed according to standard procedures, as per WHO recommendations. The overall prevalence of xerophthalmia was 8.7%. Only milder manifestations of xerophthalmia were observed. Significantly higher prevalence of xerophthalmia was observed in more than three years of age. Although nonsignificant, higher prevalence of subclinical vitamin A deficiency was observed in above three years of age group. In view of current age strategy for vitamin A supplementation (< or = 3 years) and observed higher prevalence of clinical and subclinical vitamin A deficiency above three years of age in this study (also endorsed by earlier studies) a call for review of current age strategy for vitamin A supplementation is warranted.     

Risk factors for developing mild nutritional blindness in urban Bangladesh

Mild vitamin A deficiency may be associated with increased morbidity and mortality among children in developing countries. A community-based case-control study was performed to determine risk factors for mild ophthalmologic manifestations of vitamin A deficiency in urban Bangladeshi children. Cases were identified in children less than 14 years of age with night blindness with or without other signs of mild xerophthalmia detected in a house-to-house survey. Controls were randomly selected neighbors who lacked subjective and objective ophthalmologic evidence of vitamin A deficiency. Demographic characteristics that were independently associated with vitamin A deficiency in a logistic model included male gender, greater age (mean, 6.1 years in children with cases and 2.8 years in controls), and a greater number of children living with the family. After controlling for these demographic characteristics, poor intake of locally available vitamin A-rich foods, cessation of breast-feeding, and a recent history of protracted diarrhea remained associated with vitamin A deficiency. Maternal ignorance of prevention and control of vitamin A deficiency was also associated with increased risk. The results support programs that educate mothers to breast-feed and to provide appropriate food supplements and suggest that clinicians caring for children with chronic diarrhea should initiate vitamin A supplementation.     

Control of Vitamin A Deficiency and Blindness

Vitamin A deficiency and its obvious consequences, xerophthalmia and blindness, are endemic in large parts of Asia and Africa. The prevalence of this deficiency is particularly high in countries of South-East Asia like India, Bangladesh, Nepal, Indonesia and Philippines. In African countries, most cases of childhood blindness are attributed to measles. It is most likely, however, that measles precipitates severe xerophthalmia in children whose vitamin A status is marginal.     

Vitamin A status and nutritional intake of carotenoids of preschool children in Ijaye Orile community in Nigeria

This study was carried out to determine the vitamin A status and nutritional intake of carotenoids of 213 children between the ages of 6 months and 6 years in a rural community in Nigeria. There were 109 males and 104 females. A total of 57 (26.8 per cent) children were deficient in serum retinol levels (< 10 microg/dl) while 102 (47.9 per cent) had low levels (10-19 microg/dl). The highest prevalence of serum retinol deficiency was in the 6-12 months age group, most of whom were breastfeeding and there was poor correlation between duration of breastfeeding and serum retinol levels. The prevalence of night-blindness was 1.5 per cent; however, none of the children had xerophthalmia. Chronically malnourished children had lower mean serum retinol levels than well nourished children. There was a high consumption of carotenoid-containing food, but despite this there was a high prevalence of vitamin A deficiency. We therefore suggest that measures to combat vitamin A deficiency should include vitamin A supplementation on a short-term basis. On a long-term basis parents should be educated on the importance of the consumption of locally available sources of provitamin A and pre-formed vitamin A rich foods, and the avoidance of overcooking. Parents should also be encouraged to grow more beta-carotene containing foods.     

Serum retinol-binding protein and vitamin A levels in malnourished children.

Serum levels of vitamin A and retinol-binding protein (RBP) were measured in children with vitamin A deficiency, in children with protein-energy malnutrition (PEM) and in normal children, before and after administration of 100 000 IU of water-miscible vitamin A. Serum vitamin A and RBP levels were significantly low in children with vitamin A deficiency and in children with severe PEM, whereas the values in milder grades of PEM were similar to those of normal subjects. In severely malnourished children with corneal lesions, serum vitamin A concentration was reduced to a much greater extent than the level of serum RBP. Administration of vitamin A resulted in a significant increase in serum levels of both the components within 4 hours in all the 3 groups of children. The increase in RBP concentration observed in children with PEM was similar to that in vitamin A deficient children. These results indicate that in malnourished children, particularly in those who are at risk of developing keratomalacia, vitamin A is the main limiting factor. It is, therefore, recommended that children with PEM should be treated with vitamin A in addition to dietary protein and calories.     

Assessment of preclinical vitamin A deficiency in children with persistent diarrhea

To explore the relationship between vitamin A deficiency and persistent diarrhea among young children, we studied the vitamin A status of 23 children greater than 5 years of age with persistent diarrhea by performing conjunctival impression cytology (CIC) and the relative dose-response test (RDR) as a measure of liver reserve of vitamin A. The control group consisted of 23 age- and sex-matched children who were otherwise healthy in whom CIC was performed and fasting plasma retinol values were determined. The criteria for vitamin A deficiency in CIC were paucity of goblet cells and scanty, abnormal epithelial cells. None of these children had ocular manifestations of vitamin A deficiency. Among the children with persistent diarrhea, CIC characteristic of vitamin A deficiency was found in 17 (group 1) and CIC results were normal in six (group 2). In group 1, the serum retinol levels were 1 +/- 1 microgram/dl, and RDR was 88 +/- 14. In group 2, the serum retinol levels were 8 +/- 4 micrograms/dl (p less than 0.001) and the RDR was 16 +/- 12 (p less than 0.001). In the control group, the CIC results were normal in all the children and the plasma retinol levels in these children were 19 +/- 8 micrograms/dl. In conclusion, 17 of 23 children with persistent diarrhea had abnormal CIC results, significantly low serum retinol levels, and significantly high RDR results, although they had not yet manifested xerophthalmia.(ABSTRACT TRUNCATED AT 250 WORDS)     

SERUM RETINOL-BINDING PROTEIN AND VITAMIN A LEVELS IN MALNOURISHED CHILDREN

Abstract. Reddy, V., Mohanram, M. and Raghuramulu, N. (National Institute of Nutrition, Hyderabad, India). Serum retinol-bindin protein and vitamin A levels in malnourished children. Acta Paediatr Scand 68: 65, 1979.—Serum levels of vitamin A and retinol-binding protein (RBP) were measured in children with vitamin A deficiency, in children with protein-energy malnutrition (PEM) and in normal children, before and after administration of 100000 IU of water-miscible vitamin A. Serum vitamin A and RBP levels were significantly low in children with vitamin A deficiency and in children with severe PEM, whereas the values in milder grades of PEM were similar to those of normal subjects. In severely malnourished children with corneal lesions, serum vitamin A concentration was reduced to a much greater extent than the level of serum RBP. Administration of vitamin A resulted in a significant increase in serum levels of both the components within 4 hours in all the 3 groups of children. The increase in RBP concentration observed in children with PEM was similar to that in vitamin A deficient children. These results indicate that in malnourished children, particularly in those who are at risk of developing keratomalacia, vitamin A is the main limiting factor. It is, therefore, recommended that children with PEM should be treated with vitamin A in addition to dietary protein and calories.     

Vitamin A deficiency and xerophtalmia

OBJECTIVE: To review cases of vitamin A deficiency and the effects of vitamin A supplementation on child morbidity and mortality. METHODS: Articles published in scientific journals, technical and scientific books, and also publications by international organizations were used as source of information. RESULTS: Clinical manifestations of xerophthalmia affect the retina (night blindness), the conjunctiva (conjunctival xerosis, with or without Bitot spots), and the cornea (corneal xerosis). Corneal xerosis may lead to corneal ulceration and liquefactive necrosis (keratomalacia). A priori, these signs and symptoms are the best indicators of vitamin A deficiency; they are, however, extremely rare. Laboratory indicators include Conjunctival Impression Cytology and serum retinol concentrations. The World Health Organization (WHO) recommends the use of two biological markers in order to characterize vitamin A deficiency in a given population. If only one biological marker is used, this marker has to be backed up by a set of at least four additional risk factors. Corneal xerophthalmia should be treated as a medical emergency; In the event of suspected vitamin A deficiency, a 200,000 IU vitamin A dose should be administered orally, repeating the dose after 24 hours (half the dose for infants younger than one year). Vitamin A supplementation in endemic areas may cause a 23 to 30% reduction in the mortality rate of children aged between 6 months and five years, and attenuate the severity of diarrhea. The methods for the control of vitamin A deficiency are available in the short (supplementation with megadoses), medium (food fortification), and long run (diet diversification). CONCLUSION: There is evidence of vitamin A deficiency among Brazilian children. Pediatricians must be aware of the signs and symptoms of this disease, however sporadic they might be. It is of paramount importance that vitamin A be included in public policy plans so that we can ensure the survival of children.     

Nutritional problems in urban slum children

Nutritional problems like protein energy malnutrition (PEM), anemia and vitamin A deficiency continue to plague a large proportion of Indian children. The diets and nutritional status of urban slum children in India is far away from being satisfactory. The nutritional status of slum children is worst amongst all urban groups and is even poorer than the rural average. Urban migration has not provided them salvation from poverty and undernutrition. Another distressing feature is the lack of any significant improvement over the years in this population. Most common causes of malnutrition include faulty infant feeding practices, impaired utilization of nutrients due to infections and parasites, inadequate food and health security, poor environmental conditions and lack of proper child care practices. High prevalence of malnutrition among young children is also due to lack of awareness and knowledge regarding their food requirements and absence of a responsible adult care giver. With increasing urban migration in the years ahead, the problem of malnutrition in urban slums will also acquire increasing dimension unless special efforts are initiated to mitigate the health and nutrition problems of the urban poor. Improving nutritional status of urban poor requires a more direct, more focused, and more integrated strategy.     

Screening tests for vitamin A deficiency

Objective tests for detection of xerophthalmia can solve the diagnostic problems of vitamin A deficiency under field conditions. Reliability of Rose Bengal dye test and Kajal test were tested in rural field practice area of B.J. Medical College, Pune, by finding out their correlation with prevalence of clinically detectable signs of vitamin A deficiency and serum vitamin A levels in 392 primary school children. The combination of these objective tests with clinical diagnosis may improve the detection rate of xerophthalmia.     

Serum vitamin A in relation to socio-economic, demographic and dietary characteristics in Bangladeshi children

The purpose of this study was to examine socio-economic conditions, demographic factors, use of vitamin A capsules and dietary practices in relation to the risk of low serum vitamin A. One hundred and twenty four night blind cases were identified by parents in a cross-sectional survey in Bangladesh in 1992. Age-, sex- and neighbourhood-matched controls were selected. Venous blood was collected from 87 cases and 97 controls for the determination of serum vitamin A. Information about socio-economic conditions, demographic factors, use of vitamin A capsules and dietary practices was obtained by interview. The level of serum vitamin A was strongly related to age and consumption of β-carotene rich foods. The preschool years (2-6 years) are important risk periods for vitamin A deficiency among children. We conclude that long-term prevention of vitamin A deficiency should rely on efforts to improve local diet.     

Vitamin A deficiency and child feeding in Beijing and Guizhou, China

Background  Vitamin A deficiency (VAD) is one of the three major micronutrient deficiencies in the world. In order to investigate the status of VAD and child feeding in China, we conducted the survey in Beijing city and Guizhou province. Methods  We included a high socioeconomic area (Beijing) and a low socioeconomic area (Guizhou province) in China in our study. Participants included 1236 randomly selected children aged 0-71 months from stratified clusters (628 in Beijing and 608 in Guizhou), 409 from urban and 827 from rural areas. A food intake frequency questionnaire was used for dietary assessment. Fluorescence microanalysis was carried out to measure serum retinol concentrations. Serum retinol cut-off values of less than 20 μg/dl and 30 μg/dl were defined as sub-clinical VAD and suspected sub-clinical VAD, respectively. Results  No xerophthalmia or night blindness was found. The mean concentration of serum retinol was 31.5 μg/dl in the high socioeconomic group, and 26.5 μg/dl in the low socioeconomic group. Rural infants had lower concentrations of serum retinol compared with the urban ones (26.9±8.1 μg/dl vs 31.8±7.3 μg/dl). The prevalence of sub-clinical VAD among all the children was 7.8%, and increased to 15.7% in children from the low socioeconomic group. In infants from the high socioeconomic area, the prevalence of suspected subclinical VAD was 38.0%, increasing to 59.5% in infants from the low socioeconomic area. The children from the low socioeconomic area had significantly lower frequency of intake of meat than the children in other groups. The prevalence of suspected sub-clinical VAD was higher in the children with lower consumption frequency of vitamin A rich foods than the children with higher consumption frequency of vitamin A rich foods. Conclusions  VAD appears to be a moderate public health problem in certain areas of China. In areas with low socioeconomic status, VAD in childrean is more severe, and infants may be the group at the highest risk for VAD. Inadequate intake of vitamin A rich foods may result in VAD. A comprehensive long-term national strategy needs to be fostered in China for the treatment and prevention of the deficiency.     

Mass supplementation of vitamin A linked to National Immunization Day

Objective: Main objectives were to assess the feasibility of linking vitamin A delivery with National Immunization Days (NIDs) and to see the impact on xerophthalmia.Methods: An Intervention study of mass distribution of vitamin A solution was undertaken to control widespread xerophthalmia prevalent in children living in about 26 slums of Chandigarh in the year 2000. Two rounds of mass distribution of Vitamin A solution covering 27642 and 31762 children in 1–5 years of age in first and second rounds, respectively, were undertaken. The findings of second round and post evaluation after intervention are presented here. An additional team of two persons per pulse polio immunization (PPI) centre delivered age specific doses of vitamin A solution through 98 centres and operational problems were recorded. PPI staff provided the supervision and PPI tally sheets were used.Results: The programme achieved a vitamin A coverage rate of 99% in first round and 88% in second round. Only two parents refused vitamin A solution. No side effect or cases of toxicity due to vitamin A were reported by health institutions in the area or in a stratified random sample of 101 children. There was a significant decline (13.4%) in xerophthalmia after two rounds of mass distribution (P < .001). The strategy to deliver vitamin A was successfully integrated into NID’s and appeared to achieve a significant decline in xerophthalmia.Conclusion: Linking of vitamin A distribution with PPI could be a basis for launching similar initiatives in other areas of India and other countries where xerophthalmia is a public health problem.     

Nutritional rickets without vitamin D deficiency in Bangladesh

To understand nutritional rickets in Bangladesh better, 14 rachitic and 13 'unaffected' children were evaluated. Seventy per cent of children with active rickets had no evidence of either vitamin D deficiency or familial rickets. Rickets in Bangladesh is probably related to calcium deficiency. Abnormalities in 'unaffected' children suggest that subclinical calcium insufficiency is common.     

东莞市学龄前儿童维生素A缺乏现状及维生素A对血清铁蛋白及红细胞参数的影响

目的 了解东莞市学龄前儿童维生素A缺乏现状,探讨维生素A对血清铁蛋白、红细胞及网织红细胞参数的影响。方法 于2015年4月至2016年12月通过整群抽样方法,选取东莞市无现患疾病的学龄前儿童（3~6岁）2 085例,对所选儿童进行血常规、网织红细胞计数、血清铁蛋白、血红蛋白电泳及维生素A浓度检测。分析年龄、性别与维生素A浓度及血清铁蛋白浓度的关系,维生素A浓度对血清铁蛋白、红细胞及网织红细胞参数的影响以及维生素A缺乏加重储存铁减少对红细胞参数的影响。结果 储存铁减少的儿童占比为6.71%（140/2 085）;维生素A缺乏儿童占比为32.52%（678/2 085）,其中亚临床缺乏占维生素A缺乏总人数的95.4%（647/678）,临床缺乏占维生素A缺乏总人数的4.6%（31/678）。不同性别组儿童维生素A浓度比较差异无统计学意义（P > 0.05）,但女性儿童血清铁蛋白浓度高于男性（P < 0.05）。维生素A临床缺乏组儿童血清铁蛋白浓度高于亚临床缺乏组和正常组（P < 0.05）。维生素A缺乏时,储存铁减少组平均红细胞体积和平均红细胞血红蛋白含量较储存铁正常组降低（P < 0.05）。维生素A缺乏组血红蛋白浓度、平均红细胞血红蛋白浓度、红细胞计数、红细胞压积、网织红细胞绝对值、网织红细胞百分比、网织红细胞血红蛋白含量均低于维生素A正常组,而平均红细胞体积高于维生素A正常组（P < 0.05）。结论 东莞市学龄前儿童维生素A缺乏状况仍较严重;维生素A缺乏可对血清铁蛋白、红细胞以及网织红细胞参数产生影响。     

Investigation of serum vitamin A levels of children who had a history of recurrent diarrhoea and acute respiratory infections in Ankara

Vitamin A deficiency is considered a widespread public health problem among preschool children in the developing countries. A limited number of studies reveal an association between xerophthalmia and significant systemic diseases including protein-energy malnutrition, diarrhoea, and acute respiratory infections. The present study was carried out to assess the vitamin A status of preschool children who have a history of recurrent acute respiratory infections and diarrhoea. We have already shown that serum vitamin A levels of all the study groups were lower than the control group (P less than 0.001) and the detailed statistical analyses made clear that malnutrition is the major contributing factor (P less than 0.001) although infections also have a negative effect on serum vitamin A levels (P less than 0.01). We have also shown that subclinical vitamin A deficiency is a problem of public health importance in this region, since about 64 per cent of the children examined were found to have low levels of serum vitamin A (less than 20 micrograms/dl).     

Validity of a Questionnaire Measuring Food Frequency Compared to a 7-Day Record

ABSTRACT. A questionnaire measuring food frequency was validated against 7-day records of food intake in a group of 30 children, 2–16 years of age. Special emphasis was given to the ability of the questionnaire to estimate frequency of intake of foods of particular interest in diabetes mel-litus. Fifteen children had insulin-dependent diabetes; 15 were healthy. Comparison of the two methods regarding frequency of foods with high content of sucrose, protein, fat, fibres, nitrite or vitamin C showed a correlation of 0.52–0.76. The frequency of intake of some staple foods was often overestimated by the questionnaire, while the frequency of meat, sausage and some sweet snacks was underestimated. The use of the questionnaire to identify high or low consumers of the mentioned nutrients showed a rather low sensitivity (0.38–0.50), but a high specificity (0.86–1.0) when compared with results of the 7-day record. In our limited sample of subjects no systematic differences were found comparing sexes or diabetic and healthy children. A food frequency questionnaire may, in spite of some important reservations, be a useful tool for screening purposes when more time-consuming and resource-demanding methods cannot be used.     

Nutritional vitamin B12 deficiency in hospitalized young children

The authors sought to determine prevalence, social, economic, and dietary patterns of young children (n = 20) identified as having vitamin B₁₂ deficiency anemia after admission to their hospital in the last 3 years. The diagnosis of vitamin B₁₂ deficiency was based on symptoms and clinical findings, findings on peripheral blood films and bone marrow aspirates, and serum levels of vitamin B₁₂. The children had been exclusively breast-fed without any animal food supplementation. Serum vitamin B₁₂ levels were also measured in the sera of mothers and found to be low. The authors concluded that vitamin B₁₂ deficiency might be an important health problem among children of mothers who do not consume animal foods adequately.     

Risk factors for subclinical vitamin A deficiency in children under the age of 6 years

The present study was carried out to investigate risk factors for subclinical vitamin A deficiency in children under 6 years of age in the urban slums of Nagpur, India. The study included 308 nonxerophthalmic children selected randomly from the study population. On the basis of conjunctival impression cytology the prevalence of subclinical vitamin A deficiency was estimated to be 35.7 per cent. The current study recognised a significant association between female gender, illiterate mother, lower socioeconomic status, more than two children under 5 years of age at home, undernutrition, history of diarrhoea, measles, acute respiratory infections, and subclinical vitamin A deficiency on univariate analysis. Logistic regression analysis identified significance of female gender, more than two children under 5 years of age at home, undernutrition, and measles in the outcome of subclinical vitamin A deficiency. Estimates of attributable risk proportions and population attributable risk proportions for significant and preventable risk factors confirmed their etiological and preventable role in subclinical vitamin A deficiency respectively.     

Childhood blindness due to vitamin A deficiency in India: regional variations.

OBJECTIVES--To investigate the importance of vitamin A deficiency as a cause of childhood blindness and severe visual impairment (SVI) in India. DESIGN AND SETTING--Cross sectional survey of children with visual acuity less than 6/60 in the better eye (SVI/blindness), attending 22 schools for the blind in nine states of India. MAIN OUTCOME MEASURE--Proportion of children with blindness or SVI from corneal scarring attributable to vitamin A deficiency. RESULTS--245 of 1318 (18.6%) of children had SVI/blindness attributable to vitamin A deficiency. The proportion of SVI/blindness due to vitamin A deficiency ranged from 7.5% (7/93) in Kerala to 26.7% (27/101) in Madhya Pradesh. In Tamil Nadu, 7.5% (9/120) of children in the capital city blind school had SVI/blindness due to vitamin A deficiency, compared with 30.4% (51/168) in a blind school in a rural area of the same state. CONCLUSION--Overall, vitamin A deficiency is the single most important cause of childhood blindness and SVI in India. There are marked variations by state and also between urban and rural locations.