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Vitamin A supplemntation for severe wasting

This question was posted the Prevention and treatment of severe acute malnutrition forum area and has 12 replies. You can also reply via email – be sure to leave the subject unchanged.

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Anonymous 81

Public Health Nutritionist

Normal user

15 Dec 2009, 07:44

Is it contraindicated to give Viatamin A for severe wasting during admission given the child didn't received in the last six months? until recently, my information was not to give for oedema. But last week, in one of national workshop, i was told not give even for severe wasting during admision. they recomend during the fourth week or during discharge.

Tarig Abdulgadir

CMAM Specialist / UNICEF

Normal user

15 Dec 2009, 10:54

Vitamin A supplementation method in treating children with severe wasting depend on the way of treatment wether the child will be treated as inpatient or outpatient beneficiary , if the child is inpatient care candidate then unless he/she has edema the child should receive prophylactic vitamin A upon admission once,according to his/her age , if the child is a candidate for outpatient care then he/she should receive vitamin A in the fourth visit , we should make sure that the child has not received vitamin A in the past 6 months, and if the child shown signs of vitamin A defeciency here no prophylactic regimen but instead the child can receive vitamin A therapeutic dose.the child with edema many recommendation say to give vitamin A supplementation upon discharge or after edema resolved completely as studies has shown that vitamin A supplementation in child with edema was associated with higher mortality rate.

Anne Walsh

Normal user

15 Dec 2009, 15:01

The recommendation is normally routine Vitamin A on admission for all children that are severely wasted except children with oedema. Children admitted with oedema should be given vitamin A on week 4 or on discharge. If a child has been given Vitamin A in the past 3/4/6 months (which ever interval the national guidelines state) it does not need to be repeated on admission.

The contraindication for Vitamin A in SAM was only found for children with oedema.

Michael Golden

Normal user

16 Dec 2009, 16:06

This question is often asked and many are not aware of the basis of the recommendations. They come from the work of Phillipe Donnen. First published in abstract form the papers available - abstracts and refs are as follows: This is the original abstract: available from: DAILY LOW DOSES OF VITAMIN A COMPARED WITH SINGLE HIGH DOSE IMPROVES SURVIVAL OF MALNOURISHED CHILDREN IN SENEGAL. Ph Donnen, A Sylla, M Dramaix, G Sall, N Kuakuvi, Ph Hennart. Background: Vitamin A (VA) deficiency is widely prevalent in hospitalized malnourished children in less-developed countries and mortality rates are high. Recommendation to give high doses of VA to children suffering from severe malnutrition is not sustained by results of research. Small doses of VA given regularly during hospitalization might be a better strategy to improve mortality and morbidity. Aims: To assess the effect of daily low doses of vitamin A on hospitalized malnourished children's mortality and morbidity. Methods: We did a double-blind, randomized trial in 604 and 610 Senegalese hospitalized children. The first mentioned batch received a high dose VA supplement (200.000 IU) on admission, the second a daily low dose VA supplement (5.000 IU per day) during hospitalization. Children were followed up until discharged. All cases of mortality were recorded and data on all-causes morbidity were collected daily. Results: Children of both groups were similar at baseline in terms of age and nutritional status. Low serum retinol concentrations were found in more than 75% of the study sample. Mortality was 9.7% (59 deaths) in the low doses group and 11.1% (67 deaths) in the high dose group (NS). In children without oedema on admission, mortality was similar in both treatment groups. In children with oedema on admission, mortality was significantly lower in the low doses group (Adjusted odds ratio : 0.21 ; 95% CI : 0.05-0.99). The proportion of children who never presented acute respiratory infection during hospitalization was significantly higher in the low doses group (83.5 vs. 77.8, p=0.043) whereas the proportion of children who never presented diarrhoea was not significantly different among the two groups. Median percent time ill for acute respiratory infection and diarrhoea were not significantly different in the two groups. Conclusions: In hospitalized severely malnourished children, daily low doses of VA improved mortality better than a single high dose. There have now been two full papers published - one a full report of the Senegal study and the other from DRC: Donnen P, Sylla A, Dramaix M, Sall G, Kuakuvi N, Hennart P. Effect of daily low dose of vitamin A compared with single high dose on morbidity and mortality of hospitalized mainly malnourished children in senegal: a randomized controlled clinical trial. Eur J Clin Nutr 2007 December;61(12):1393-9. Abstract: BACKGROUND: In vitamin A-deficient populations, children hospitalized with infections and/or malnutrition are at particular risk of developing severe vitamin A (VA) deficiency. High-dose VA supplements are recommended as part of the treatment but results on its effect on recovery from morbidity and on prevention from nosocomial morbidity are conflicting. OBJECTIVE: We aimed to assess the effect of a single high dose and daily low dose of VA on hospitalized malnourished children's morbidity. DESIGN: We carried out a double-blind, randomized trial in 604 and 610 Senegalese hospitalized children. The first mentioned batch received a high-dose VA supplement (200,000 IU) on admission, the second a daily low-dose VA supplement (5000 IU per day) during hospitalization. Children were followed up until discharged. Data on all-cause morbidity were collected daily. RESULTS: Survival analysis showed that the incidence of respiratory disease was significantly lower in the low-dose group than in the high-dose group, hazard ratios (HR): 0.26, 95% CI: 0.07-0.92. The duration of respiratory infection was also significantly lower in the low-dose group than in the high-dose group (HR of cure: 1.41, 95% CI: 1.05-1.89). Duration and incidence of diarrhoea were not significantly different between treatment groups. In children with oedema on admission, mortality was significantly lower in the low-dose group (Adjusted odds ratio: 0.21; 95% CI: 0.05-0.99). CONCLUSIONS: Daily low dose of VA compared with single high dose significantly reduced duration and incidence of respiratory infection but not of diarrhoea in hospitalized children Donnen P, Dramaix M, Brasseur D, Bitwe R, Vertongen F, Hennart P. Randomized placebo-controlled clinical trial of the effect of a single high dose or daily low doses of vitamin A on the morbidity of hospitalized, malnourished children. Am J Clin Nutr 1998 December;68(6):1254-60. Abstract: The effect of high-dose vitamin A supplementation on recovery from morbidity and on recovery from nosocomial morbidity of hospitalized children has been poorly studied and results are conflicting. The effect of daily, low doses has never been assessed. We investigated the effect of a single high dose and daily, low doses of vitamin A on diarrhea, acute lower respiratory tract infections (ALRIs), and all-cause fevers in 900 hospitalized preschool-age children in the Democratic Republic of Congo in a randomized, double-blind, placebo-controlled clinical trial. The high-dose treatment group received 200,000 IU vitamin A (100,000 IU if aged <12 mo) orally on the day of admission, the low-dose treatment group received 5000 IU vitamin A/d until discharge. Data on all-cause morbidity were collected daily. Mortality rates were not significantly different among the 3 groups. High-dose vitamin A supplementation had no significant effect on the duration of moderate or severe diarrhea nor on the duration and incidence of ALRIs and all-cause fevers. Children in the high-dose group with no edema had an increased risk of severe nosocomial diarrhea (relative risk: 2.42; 95% CI: 1.15, 5.11). Low-dose vitamin A supplementation significantly reduced the incidence of severe diarrhea in severely malnourished children (relative risk: 0.21; 95% CI: 0.07, 0.62) but showed no significant effect on the duration of moderate or severe diarrhea or on the duration and incidence of ALRIs and all-cause fevers. Supplementation with high doses of vitamin A did not reduce morbidity in this population of malnourished and subclinically vitamin A-deficient children; daily, low doses appeared more beneficial for severely malnourished children In Summary - in DRC the low dose group marasmic children had less severe diarrhoea (one fifth as much). In Senegal there was less RTI (one quarter) - the mortality rate was lower in the Oedematous children. It would seem that in both marasmic children and kwash there is no advantage in giving high dose vit A on admission and these RCTs show that there is likely to be a detrimental effect on diarrhoea and/or RTI and for the kwash children mortality. Thus, my current recommendations are: 1) if F100/F75/RUTF is being given then there is sufficient vitamin A already in these products to supply enough vitamin A for routine situations 2) where other products have to be used because of unavailability of the correct formulations then either vitamin A can be added to the formulation on a daily basis or capsules can be given. 3) Vitamin A capsules shoule continue to be given ON AN INDVIDUAL CHILD basis if there are: a) any clinical signs of vitamin A deficiency in that child. b) if the child has, or has been exposed to measles (or during a measles epidemic). Routine treatment with high doses could be extended to areas where there is a high prevalence of symptomatic vitamin A deficiency (now thankfully relatively rare) and possibily to areas were both vitamin A capsule distribution AND measles coverage are very low. These latter recommedations are likely to change as the subject is studied further. I addressed the possible mechanisms for this effect in a presentation to WHO some years ago. The main side effect of vit A overdose is increased cerebro-spinal fluid accumulation (pseudo-tumour cerebrae) - it would appear that large doses of Vit A can have an effect upon salt and water transport and this could affect electrolyte imbalance, particularly in Kwash - but the elucidation requires further studies in tissues, animals and man.

Michael Golden

Normal user

16 Dec 2009, 16:19

I should have added that a 10 kg child taking maintenance amounts of F75 (1000kcal) will receive 7300 IU (2.2mg) of Vitamin A per day. (The RDA(USA) for such a child is 1700 IU (0.5mg) per day - which covers 95% of the populations needs in health). A 7kg child will get about 5100IU - the amount given by Donnen in his studies. During catch up growth when the children are taking up to 200kcal/kg of RUTF/F100 the intake will be twice this amount. These quantities are sufficient to treat MILD vitamin A deficiency and to replete stores - albeit gradually.

A full preventative dose can then be given at discharge - or week 4 to catch any defalters - when the retinol binding protein level has returned to normal and the Ito cells of the liver have regenerated (the Ito cells are the specialised cells that store Vitamin A - in biopsies of the liver in SAM they are exceptionally difficult to find and are probably so reduced in number that they cannot store the vitamin A during the acute phase).

Anonymous 81

Public Health Nutritionist

Normal user

16 Dec 2009, 18:57

Thanks for Michael, Anne and Tarik,

MY take home message is as follow (if am wrong, i will be corrected)

" Any severely acute malnourished child (whether oedematous or wasted) admited either to stablization center or outpatient therapeutic programme should not received Vitamin A during admission. It can then be given at discharge - or week 4 to catch any defalters"

Thanks

Michael Golden

Normal user

16 Dec 2009, 23:43

Dear Anonymous.
NOTE that I did NOT say that the children should'nt get vitamin A.
What I did say was that they should get around 5000 to 15000IU per day and not a MEGAdosage that is designed as a public health expedient to last children for up to 6 unsupervised months on their normal diet.
With SAM the children are under supervision and are being seen daily if inpatients and weekly if outpatients - we can easily give them the correct therapeutic doseage within a physiological range during this time - it so happens when I designed F75 and F100 I incorporated modest doses of vitamin A (about 4 times the RNI) in order to correct mild vitamin A deficiency and restor stores of vitamin A.
The giving of Vitamin A capsules routinely in SAM is partly a hang over from the days when children were being treated with high energy milk (usually devoid of vitamin A) and partly through the insistance of a few who are not up to date with the evidence..
Neither giving NO Vitamin A at all, on one hand, and giving 6months worth of vitamin A routinely on admission on the other are the right way forward - give reasonable doses - that is what you are doing with modern therapeutic foods for SAM.

Interestingly, although the giving of vitamin A has been shown in many studies to reduce mortality at a poplation level. A cocharane review on vitamin A and RTI prevention contains the following sentence: "We do not recommend giving vitamin A to all children to prevent acute LRTIs because a few studies unexpectedly found vitamin A increased the chance of infections or worsened symptoms. Some evidence shows benefit for vitamin supplements given to children with low serum retinol (or with poor nutritional status)." -quoted from Chen H, Zhuo Q, Yuan W, Wang J, Wu T. Vitamin A for preventing acute lower respiratory tract
infections in children up to seven years of age. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD006090. DOI: 10.1002/14651858.CD006090.pub2.

Sheikh

Physician

Normal user

20 Jan 2013, 15:28

Is there any role of Vitamin A in respiratory tract infection/cough/asthma/copd both in adult & children? If the answer is yes then what will be the dose ?

Atif

Normal user

14 May 2014, 04:33

Some discussion made in 2013 Guidelines of WHO. (Updates on the management Of severe acute malnutrition In infants and children)
• Low-dose (5000 IU) vitamin A supplementation given daily to children with severe acute
malnutrition, from the time of admission until discharge from treatment, is more effective in
reducing the mortality of children with oedema, the incidence of severe diarrhoea, and the
incidence and duration of respiratory infection than single high-dose vitamin A supplementation(100 000 IU for children who are less than 1 year of age; 200 000 IU for children aged 1 year or older) on day 1 of admission;
• High-dose vitamin A supplementation appears to confer some benefit (compared to receiving no supplementation at all) in children with severe acute malnutrition who present with severe diarrhoea or shigellosis or have clear signs of vitamin A deficiency;
• The evidence for the efficacy and safety of vitamin A supplementation in children with severe acute malnutrition with non-measles pneumonia and other acute lower respiratory tract infections is inconclusive;
• High-dose vitamin A supplementation reduces mortality in children with severe acute malnutrition complicated by measles-specific respiratory infections.

Kirrily de Polnay

Medical Doctor/Research Associate

Normal user

23 Jul 2014, 13:06

It's been really interesting to read these responses. Could anyone give me some more references about why we don't give vitamin A to SAM children with oedema?

I followed these guidelines when I was working with SAM children in Sierra Leone, however I had one child who was SAM with oedema 3+, he was in quite a bad condition, also with malaria. His oedema was pretty resistant but eventually started to respond to treatment. He had no history of measles though the vaccination history was unclear. He had no history of eye problems and nothing seen in his initial examinations. I didn't see him for 48 hours due to night shifts and when I next came back he had a corneal ulcer. I referred him to the government eye clinic who said his vision was lost. I couldn't help but wonder whether vitamin A could have prevented this and would the balance of harm with oedema been less than losing his vision.

hesbon rasiene

nutritionist

Normal user

3 Apr 2017, 08:47

mostly the vitamin A capsules are normally in 50,000,10,000 and 200,000 iu so how can one come up with 5000 iu?

Mary Oyunga

Senior Research Officer/ KALRO

Normal user

3 Apr 2017, 11:47

I imagine that you want to use VA for frequent use in small doses. Ideally you would purchase from the normal suppliers by odering what you need but if this is not possible, do a calculation and then add only what is required for your intervention vehicle from the VA you have

André BRIEND

Frequent user

3 Apr 2017, 12:40

The 5000 IU/day of Vitamin A corresponds to the dose received on average by a child consuming the recommended amounts of F-75 and RUTF. See discussion above.

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