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Vitamin A for SAM Children

This question was posted the Management of wasting/acute malnutrition forum area and has 6 replies.

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Anonymous 1310

Nutrition Manager

Normal user

8 Dec 2016, 13:00


Should Vitamin A be given to SAM children or not?
If Vitamin A should not be given, why?

If Vitamin A should be given, when? at admission or discharge or on which visit?

Joseph lotesiro

nutrition assistant

Normal user

8 Dec 2016, 19:00

Vitamin A , should be given to children with SAM on daily basis throughout the course of treatment but not in high dosage but in a dosage of 5000 I.u daily, because F-75,F-100 and RUTF contain vitamin A.

Jessica Bourdaire

Normal user

9 Dec 2016, 09:58

Anonymous 1310,
Below I refer to the 2013 WHO recommendations but you might need to refer to the guideline used in the country you are working in.

Should Vitamin A be given to SAM children or not?
Yes, about 5000IU/day are recommended, a daily low-dose, as opposed to a single high-dose (50 000IU/100 000IU/200 000IU). A high-dose is not required when receiving vitamine A through therapeutic food or formulations complying with WHO specifications. Two exceptions though, if SAM is associated with measles or eye signs of vitamin A deficiency, a high-dose is recommended at D1, D2 and D15.

If Vitamin A should not be given, why?
It should be given. A daily low-dose is thought to be safer and more effective in reducing RTI/diarrhoea occurrence, and kwash mortality, than a single high-dose.

If Vitamin A should be given, when? at admission or discharge or on which visit?
A daily low-dose from admission and throughout the treatment. Punctual high-doses are reserved to the above-mentioned exceptions, or if a daily low-dose is not provided.

The guideline gives details on the evidence supporting its recommendations:
http://www.who.int/nutrition/publications/guidelines/updates_management_SAM_infantandchildren/en/

Hope this helps,
Jess

Anonymous 3285

Normal user

25 Feb 2021, 15:24

It's so confusing, some say we need to Provide vitamin A in small dose while other contradict saying not to provide, In our country's guideline, it is recommended vitamin A to be provided during discharge if the child is edematous. So I want to know the reason why we can't provide vitamin A to edematous children with SAM?

Ashfaque Qureshi

Normal user

25 Feb 2021, 16:36

it is safe to give single dose at the time of admission of 100 000IU of vit-A capsule

Mohammed Mudarrifu

Nutrition Officer-HSS

Normal user

25 Feb 2021, 17:21

Vitamin A cannot be given to an Oedmatous patients because Oedema is an accumulation of fluids in the body tissue and Retinol is a fat soluble substance so when given to an oedema patient, it cannot be absorbed by the body tissue.. i stand to be corrected.

Paul

Action Against Hunger UK

Technical expert

25 Feb 2021, 18:14

Hi Anonymous,

What Jessica has written above is correct. This issue has also been discussed in previous posts on en-net; please see the inputs from Anne Walsh and Michael Golden in this post

https://www.en-net.org/question/171.aspx

There are lots of variations on protocols but some history may help to put this into context. The original reason for NOT giving Vitamin A in CMAM programmes was based on limited evidence that suggested a higher mortality rate if children with oedematous malnutrition were given high dose Vitamin A on admission. 

Studies also indicated that daily low dose vitamin A (5000 iu per day) was better for children with SAM with a reduction in morbidity (see the post above and the systematic review by Mark Manary et al. below for detailed discussion)

https://www.who.int/nutrition/publications/guidelines/updates_management_SAM_infantandchildren_review3.pdf

Two things emerged, firstly that the vitamin A content in therapeutic milks and RUTF was likely more appropriate than giving high dose vitamin A on admission to treatment - unless there was the risk of more serious issues such as blindness or death - such that the exception is to give vitamin A to children with vitmain A deficiency with eye signs or with a diagnosis of measles. However, if the therapeutic milk is homemade then adding vitamin A (eg through mineral and vitamin mix) would be appropriate. 

Secondly a variation in when, and if, to give vitamin A to oedematous cases arose in guidelines. Some practiitioners suggested that high dose vitamin A should still be given to oedematous cases but only when the oedema had resolved. However protocols being protocols, some guidelines standardised this by saying that vitamin A should be given on week 4; this was to coincide with the giving of measles vaccinations in week 4 (another compromise in some guidelines) or by giving it on discharge. Reading national guidelines one can become confused by the array of interpretations.

Going back to Jessica's reply indicating vitamin A shouldn't be given provided that the child is being given therapeutic foods that comply with WHO standards (i.e. contain vitamin A which will thus be given in a daily low dose in the diet) - except where there are eye signs or mealses, when high doses are required; The dose of vitamin A to be given in these exceptions is dependent on the child's age. Jessica's advice follows the WHO 2013 guidance.  You should however comply with any national guidelines as these are usually constructed to accomodate other relevant governmental guidance and adaptations to context. 

I hope this helps,

Paul

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