Vitamin A Supplementation
This tool explains the importance of vitamin A to good health and describes the treatment protocols for vitamin A supplementation in the major instances when this may be necessary: among young children who may have a deficiency of vitamin A or who have been diagnosed with chicken pox or protein energy malnutrition, and among postpartum women. It gives the daily recommended safe intake of vitamin A for children and pregnant and lactating women and the estimated vitamin A concentrations in a variety of common foods. It could be used by teachers in the classroom or by those responsible for health services at the school, and/or to develop parent education materials.
I. Introduction
What is vitamin A?Vitamin A is an essential nutrient needed in small amounts for the normal functioning of the visual system, for growth and development, for the maintenance of epithelial cellular integrity, immune function, and reproduction. It is present in foods such as whole milk, breast milk, butter and liver. In addition, carotenoids—substances that can be converted to vitamin A in the body—are present in red palm oil, yellow and orange fruits and vegetables and dark green leafy vegetables.
Who needs vitamin A?Everybody needs vitamin A to protect his/her health and vision. Women who breastfeed especially need vitamin A to help them stay healthy, and to pass vitamin A to their children through breast milk. Young children need vitamin A after they are weaned to help them to grow, develop normally and stay healthy.
Vitamin A helps to protect our health and vision in several ways:
· Reduced severity of infectionsVitamin A helps to decrease the severity of many infections, such as diarrhoea and measles.
· Increased chances of survivalWhen young children receive the vitamin A they need, they are more likely to survive an infection.
· GrowthVitamin A is necessary for growth. Young children have a special need for vitamin A because they are growing rapidly. Pregnant women need vitamin A to help the growth of their unborn child.
· Sight and the eyesVitamin A is vital for the proper functioning of the eyes. The transparent part of the eye, the cornea through which one sees, is protected by vitamin A. If there is shortage of vitamin A, it may be difficult to see in dim light. A severe shortage of vitamin A may result in blindness.
Vitamin A deficiencyThe body cannot make vitamin A, so all the vitamin A we need must come from what we eat. However, the body stores any extra vitamin A we eat to create a reserve for times of need. When the reserve is low, and we do not eat enough foods containing vitamin A to meet our body’s needs, we say that there is vitamin A deficiency. When there is vitamin A deficiency, many infections are more severe.
Vitamin A supplementsVitamin A solution in capsulesYoung children and women who are not getting the vitamin A they need from the food they are eating can be given a concentrated form of the vitamin like a medicine. This is called vitamin A supplementation. Vitamin A supplementation is given by mouth.
II. How to store vitamin A supplements
Vitamin A supplements are more stable than vaccines. However, air and sunlight will damage the vitamin. Vitamin A in the capsules should:
§ be kept out of direct sunlight§ be kept cool§ not be frozen
Vitamin A supplements do not need a cold chainand need not be stored in a refrigerator.
Unopened, vitamin A supplements will keep their potency under good conditions of storage for at least two years. However, once a bottle containing vitamin A capsules is opened, the capsules should be used within one year.
§ Write the date on the label when you open a new bottle containing capsules, so that you will know when to stop using it.
§ Always check the expiration date printed on the label of the bottles of vitamin A capsules.
§ Storage of the 100,000 IU and 200,000 IU capsules (generally of different colours) should be separate and clearly identified, so as not to mix up the two doses.
III. How to give vitamin A supplements using capsules
Using the capsules
Check the label to determine the dose of vitamin A supplement contained in each capsule.
Check the expiration date on the label.
A health worker or other trained person should administer the dose of vitamin A to the child. Make sure that the child swallows the content of the capsule and does not spit out any drops.
Discard used capsules in the appropriate container.
Cutting the capsules
Open the capsule by cutting across the nipple with a clean pair of scissors.
To avoid finger pricks, do not use pins to open the capsules.
Do not open capsules with your teeth.
Dispensing the capsules
Squeeze the sides of the capsule firmly, and carefully drop all the contents of the capsule into the mouth of the recipient.
IV. Giving vitamin A supplements to children
Dosing schedule
Step 1: ScreeningFrom the age of six months, children should be screened to determine eligibility for a dose of vitamin A at all immunization and other health contacts. Eligibility can be determined by checking the immunization or child health card for the last date of vitamin A supplementation. Vitamin A supplements can be safely given at the same time as vaccines.
Step 2: DosingThe schedule for giving vitamin A supplements to young children to prevent vitamin A deficiency is shown in Table 1.
Table 1: Vitamin A Dosing Schedule to Prevent Vitamin A DeficiencyCHILDREN 6 TO 59 MONTHS OF AGEAgeDoseFrequencyChildren: 6-11 months100,000 IU (30mg)Once every 4-6 monthsChildren: 12-59 months200,000 IU (60mg)Once every 4-6 months
Instruct the parent to return with the child for the next appropriate dose of vitamin A supplement. (The health worker may want to give the parent a piece of paper showing the next date of vitamin A supplementation.)
Route of administration of vitamin A supplements:Vitamin A supplements for prevention of vitamin A deficiency are given by mouth. Vitamin A supplements presented in capsules should never be given by injection.How often do you need to give vitamin A supplements?Vitamin A supplements give protection against vitamin A deficiency for a period of 4 to 6 months. Therefore, it is recommended to give a vitamin A supplement every 4 to 6 months to young children who do not receive the amount they need from their food.
Labelling of vitamin A supplements:Preparations of vitamin A supplements are labelled in international units, often shortened to IU. Preparations also may be labelled in milligrams (mg) or micrograms (mg). Always check the manufacturer’s instructions.
Contraindications to giving vitamin A supplements:There are no contraindications to giving vitamin A supplements to children.
Side effects:Usually there are no side effects. However, sometimes a child may eat less for a day, or there could be some vomiting or headache. Advise the mother/parent that this is normal, that the symptoms will pass and that no specific treatment is necessary.
V. Giving vitamin A supplements to mothers
Dosing schedule
Step 1: Screening· Pregnant women and women of child-bearing age: Pregnant women, or women of childbearing age who may be in the early stages of pregnancy without knowing it, should not be given large dose vitamin A supplements (over 10,000 IU). Large dose vitamin A supplements given early in pregnancy may damage the unborn child.
· Women up to six weeks postpartum: It is only safe to give large dose vitamin A supplements (over 10,000 IU) to women of childbearing age within six weeks after delivery. At this time, there is almost no chance that the mother is pregnant.
Vitamin A supplements given to a lactating mother will increase vitamin A levels not only in her own body reserves but also in breast milk and therefore her breastfed newborn.
Step 2: Dosing:Mothers should receive vitamin A supplementation in two doses. The first dose of vitamin A should be provided immediately after delivery of the child at a health facility or during the first postnatal contact with a health worker, and a second dose should be given at least 24 hours after the first dose and within six weeks after delivery. Supplements may also be given daily or weekly in low doses during the first six months after delivery.
Table 2: Vitamin A Dosing Schedule to Prevent Vitamin A DeficiencyWOMEN UP TO SIX WEEKS POSTPARTUMFrequencyTimingDoseFirst dose
Second doseImmediately after delivery
24 hours after the first dose, within 6 weeks after delivery200,000 IU (60mg)
200,000 IU (60mg)Or, DailyUp to six weeks after delivery10,000 IU (3mg)Or, WeeklyUp to six weeks after delivery25,000 IU (7.5mg)
VI. Assuring adequate vitamin A to infants through breastfeeding
When a lactating mother has sufficient vitamin A stores, she passes vitamin A through breast milk to her child and ensures its adequate vitamin A status.
Mothers should breastfeed their children for the first six months exclusively, i.e., without giving other foods or liquids. After six months, mothers should introduce complementary foods but continue to breastfeed for up to two years.
Promote exclusive breastfeeding during the first six monthsand explain the benefits of breastfeeding for both the mother and child.
Advise mothers on how to breastfeed adequately.
Some breastfeeding recommendations are as follows:
§ Mothers should start breastfeeding shortly after delivery (within the first hour).§ Mothers should be instructed on the proper attachment of the child to the breast.§ The child should be breastfed as often and as long as he/she wants, day and night, up to every 2½ to 3 hours or between 8 to 12 times a day.§ Mothers should not give their children any food or drink, including water, other than breast milk during the first six months. Feeding bottles and pacifiers should not be used.§ Mothers should consume a balanced diet and drink sufficient liquids in order to ensure a good milk supply.Frequent breastfeeding is desirable because it stimulates adequate breast milk production to meet the daily requirements of the child.
VII. Vitamin A supplements in treatment of measles
Children with measles infection should be provided high dose vitamin A supplementation. Administration of vitamin A to children at the time of measles diagnosis decreases both the severity of disease and the case fatality rate. Children who live in areas where measles is a common infection should also receive vitamin A supplementation as a preventative measure.
Dosing:
— The first dose of vitamin A should be administered on the day of measles diagnosis, with the exact dosage depending on age.— The second dose should be administered the following day.— When the mother is not able to return for the second dose, she should be given the vitamin A supplement to administer at home.
Table 3: Vitamin A Treatment Schedule During Measles:CHILDREN 0 TO 59 MONTHS OF AGEAgeFirst DoseImmediately on diagnosisSecond DoseNext dayChildren: 0-5 months50,000 IU (15mg)50,000 IU (15mg)Children: 6-11 months100,000 IU (30mg)100,000 IU (30mg)Children: 12-59 months200,000 IU (60mg)200,000 IU (60mg)
VIII. Vitamin A supplements in treatment of severe protein-energy malnutrition
Children with severe protein-energy malnutrition (PEM) are at increased risk of having or developing vitamin A deficiency. Any child with severe malnutrition, showing visible wasting or oedema of both feet, should be given a high dose of vitamin A supplement immediately on diagnosis and referred to the hospital for treatment.
High dose vitamin A supplements should only be administered to children who have not already received vitamin A supplementation within the last four weeks.
Dosing:
— A single high dose of vitamin A supplement, according to age, should be given to children with severe malnutrition immediately on diagnosis.
Table 4: Vitamin A Treatment Schedule During Severe Protein-Energy MalnutritionCHILDREN 0 TO 59 MONTHS OF AGEAgeDoseFrequencyChildren: 0-5 months50,000 IU (15mg)One doseChildren: 6-11 months100,000 IU (30mg)One doseChildren: 12-59 months200,000 IU (60mg)One dose
IX. Assuring sufficient vitamin A through food sources: Dietary diversification
A variety of foods should be eaten every day. Vitamin A can be derived from meat, fish, milk and dairy products and plant foods. Carotenoids, precursors that change into vitamin A in the body, are present in dark green vegetables and orange-coloured fruits and vegetables.
— Vitamin A from animal sources and breast milk is better utilized by the body than carotenoids from plant sources.— Introduce fruit and vegetable home gardens to have better access to a variety of vitamin A-rich foods.— Consume preserved, dried and fortified foods when fresh fruits and vegetables are temporarily unavailable in order to assure a diverse diet year round.
How to prepare foods to increase vitamin A intake:
§ Cut, shred or grind vegetables into small pieces.§ Add a small amount of oil or fat to the meal (½ to 1 teaspoon), preferably canola oil, corn oil or sunflower oil, during mixing and preparation.§ Boil or steam vegetables for a short period of time, preferably with a lid on the pot.§ Avoid long cooking of vegetables under high temperatures.§ Consume foods immediately after preparation, not allowing them to sit for extended periods of time.§ Store fresh fruits and vegetables in a cool and dry place without exposure to sunlight.§ Sun-dry fruits and vegetables as a method of storing and preserving them.
The recommended safe intake levels to meet the vitamin A requirements for infants and children and pregnant and lactating women are indicated in Table 3. Pregnant and lactating women need to consume foods containing sufficient vitamin A for both mother and child.
Table 5: Daily Recommended Safe Intake of Vitamin AINFANTS AND CHILDREN µg RE/day0-6 months 3757-12 months 4001-3 years 4004-6 years 4507-9 years 50010-18 years (male or female) 600ADULTS µg RE/dayPregnant women 800Lactating women 8501 µg RE (Retinol Equivalents) = 3.33 IU vitamin ASource: FAO/WHO, Geneva, 2000
Table 6 indicates the estimated vitamin A concentrations in a variety of common foods.
Table 6: Common Foods and their Estimated Vitamin A ConcentrationsFOOD UNITS µg REMature breast milk (>21 days postpartum)a 500 µg RE/LBeef liver, raw 100g 10,503Carrot, raw 100g 2,813Sweet potato, mashed 100g
http://portal.unesco.org
I. Introduction
What is vitamin A?Vitamin A is an essential nutrient needed in small amounts for the normal functioning of the visual system, for growth and development, for the maintenance of epithelial cellular integrity, immune function, and reproduction. It is present in foods such as whole milk, breast milk, butter and liver. In addition, carotenoids—substances that can be converted to vitamin A in the body—are present in red palm oil, yellow and orange fruits and vegetables and dark green leafy vegetables.
Who needs vitamin A?Everybody needs vitamin A to protect his/her health and vision. Women who breastfeed especially need vitamin A to help them stay healthy, and to pass vitamin A to their children through breast milk. Young children need vitamin A after they are weaned to help them to grow, develop normally and stay healthy.
Vitamin A helps to protect our health and vision in several ways:
· Reduced severity of infectionsVitamin A helps to decrease the severity of many infections, such as diarrhoea and measles.
· Increased chances of survivalWhen young children receive the vitamin A they need, they are more likely to survive an infection.
· GrowthVitamin A is necessary for growth. Young children have a special need for vitamin A because they are growing rapidly. Pregnant women need vitamin A to help the growth of their unborn child.
· Sight and the eyesVitamin A is vital for the proper functioning of the eyes. The transparent part of the eye, the cornea through which one sees, is protected by vitamin A. If there is shortage of vitamin A, it may be difficult to see in dim light. A severe shortage of vitamin A may result in blindness.
Vitamin A deficiencyThe body cannot make vitamin A, so all the vitamin A we need must come from what we eat. However, the body stores any extra vitamin A we eat to create a reserve for times of need. When the reserve is low, and we do not eat enough foods containing vitamin A to meet our body’s needs, we say that there is vitamin A deficiency. When there is vitamin A deficiency, many infections are more severe.
Vitamin A supplementsVitamin A solution in capsulesYoung children and women who are not getting the vitamin A they need from the food they are eating can be given a concentrated form of the vitamin like a medicine. This is called vitamin A supplementation. Vitamin A supplementation is given by mouth.
II. How to store vitamin A supplements
Vitamin A supplements are more stable than vaccines. However, air and sunlight will damage the vitamin. Vitamin A in the capsules should:
§ be kept out of direct sunlight§ be kept cool§ not be frozen
Vitamin A supplements do not need a cold chainand need not be stored in a refrigerator.
Unopened, vitamin A supplements will keep their potency under good conditions of storage for at least two years. However, once a bottle containing vitamin A capsules is opened, the capsules should be used within one year.
§ Write the date on the label when you open a new bottle containing capsules, so that you will know when to stop using it.
§ Always check the expiration date printed on the label of the bottles of vitamin A capsules.
§ Storage of the 100,000 IU and 200,000 IU capsules (generally of different colours) should be separate and clearly identified, so as not to mix up the two doses.
III. How to give vitamin A supplements using capsules
Using the capsules
Check the label to determine the dose of vitamin A supplement contained in each capsule.
Check the expiration date on the label.
A health worker or other trained person should administer the dose of vitamin A to the child. Make sure that the child swallows the content of the capsule and does not spit out any drops.
Discard used capsules in the appropriate container.
Cutting the capsules
Open the capsule by cutting across the nipple with a clean pair of scissors.
To avoid finger pricks, do not use pins to open the capsules.
Do not open capsules with your teeth.
Dispensing the capsules
Squeeze the sides of the capsule firmly, and carefully drop all the contents of the capsule into the mouth of the recipient.
IV. Giving vitamin A supplements to children
Dosing schedule
Step 1: ScreeningFrom the age of six months, children should be screened to determine eligibility for a dose of vitamin A at all immunization and other health contacts. Eligibility can be determined by checking the immunization or child health card for the last date of vitamin A supplementation. Vitamin A supplements can be safely given at the same time as vaccines.
Step 2: DosingThe schedule for giving vitamin A supplements to young children to prevent vitamin A deficiency is shown in Table 1.
Table 1: Vitamin A Dosing Schedule to Prevent Vitamin A DeficiencyCHILDREN 6 TO 59 MONTHS OF AGEAgeDoseFrequencyChildren: 6-11 months100,000 IU (30mg)Once every 4-6 monthsChildren: 12-59 months200,000 IU (60mg)Once every 4-6 months
Instruct the parent to return with the child for the next appropriate dose of vitamin A supplement. (The health worker may want to give the parent a piece of paper showing the next date of vitamin A supplementation.)
Route of administration of vitamin A supplements:Vitamin A supplements for prevention of vitamin A deficiency are given by mouth. Vitamin A supplements presented in capsules should never be given by injection.How often do you need to give vitamin A supplements?Vitamin A supplements give protection against vitamin A deficiency for a period of 4 to 6 months. Therefore, it is recommended to give a vitamin A supplement every 4 to 6 months to young children who do not receive the amount they need from their food.
Labelling of vitamin A supplements:Preparations of vitamin A supplements are labelled in international units, often shortened to IU. Preparations also may be labelled in milligrams (mg) or micrograms (mg). Always check the manufacturer’s instructions.
Contraindications to giving vitamin A supplements:There are no contraindications to giving vitamin A supplements to children.
Side effects:Usually there are no side effects. However, sometimes a child may eat less for a day, or there could be some vomiting or headache. Advise the mother/parent that this is normal, that the symptoms will pass and that no specific treatment is necessary.
V. Giving vitamin A supplements to mothers
Dosing schedule
Step 1: Screening· Pregnant women and women of child-bearing age: Pregnant women, or women of childbearing age who may be in the early stages of pregnancy without knowing it, should not be given large dose vitamin A supplements (over 10,000 IU). Large dose vitamin A supplements given early in pregnancy may damage the unborn child.
· Women up to six weeks postpartum: It is only safe to give large dose vitamin A supplements (over 10,000 IU) to women of childbearing age within six weeks after delivery. At this time, there is almost no chance that the mother is pregnant.
Vitamin A supplements given to a lactating mother will increase vitamin A levels not only in her own body reserves but also in breast milk and therefore her breastfed newborn.
Step 2: Dosing:Mothers should receive vitamin A supplementation in two doses. The first dose of vitamin A should be provided immediately after delivery of the child at a health facility or during the first postnatal contact with a health worker, and a second dose should be given at least 24 hours after the first dose and within six weeks after delivery. Supplements may also be given daily or weekly in low doses during the first six months after delivery.
Table 2: Vitamin A Dosing Schedule to Prevent Vitamin A DeficiencyWOMEN UP TO SIX WEEKS POSTPARTUMFrequencyTimingDoseFirst dose
Second doseImmediately after delivery
24 hours after the first dose, within 6 weeks after delivery200,000 IU (60mg)
200,000 IU (60mg)Or, DailyUp to six weeks after delivery10,000 IU (3mg)Or, WeeklyUp to six weeks after delivery25,000 IU (7.5mg)
VI. Assuring adequate vitamin A to infants through breastfeeding
When a lactating mother has sufficient vitamin A stores, she passes vitamin A through breast milk to her child and ensures its adequate vitamin A status.
Mothers should breastfeed their children for the first six months exclusively, i.e., without giving other foods or liquids. After six months, mothers should introduce complementary foods but continue to breastfeed for up to two years.
Promote exclusive breastfeeding during the first six monthsand explain the benefits of breastfeeding for both the mother and child.
Advise mothers on how to breastfeed adequately.
Some breastfeeding recommendations are as follows:
§ Mothers should start breastfeeding shortly after delivery (within the first hour).§ Mothers should be instructed on the proper attachment of the child to the breast.§ The child should be breastfed as often and as long as he/she wants, day and night, up to every 2½ to 3 hours or between 8 to 12 times a day.§ Mothers should not give their children any food or drink, including water, other than breast milk during the first six months. Feeding bottles and pacifiers should not be used.§ Mothers should consume a balanced diet and drink sufficient liquids in order to ensure a good milk supply.Frequent breastfeeding is desirable because it stimulates adequate breast milk production to meet the daily requirements of the child.
VII. Vitamin A supplements in treatment of measles
Children with measles infection should be provided high dose vitamin A supplementation. Administration of vitamin A to children at the time of measles diagnosis decreases both the severity of disease and the case fatality rate. Children who live in areas where measles is a common infection should also receive vitamin A supplementation as a preventative measure.
Dosing:
— The first dose of vitamin A should be administered on the day of measles diagnosis, with the exact dosage depending on age.— The second dose should be administered the following day.— When the mother is not able to return for the second dose, she should be given the vitamin A supplement to administer at home.
Table 3: Vitamin A Treatment Schedule During Measles:CHILDREN 0 TO 59 MONTHS OF AGEAgeFirst DoseImmediately on diagnosisSecond DoseNext dayChildren: 0-5 months50,000 IU (15mg)50,000 IU (15mg)Children: 6-11 months100,000 IU (30mg)100,000 IU (30mg)Children: 12-59 months200,000 IU (60mg)200,000 IU (60mg)
VIII. Vitamin A supplements in treatment of severe protein-energy malnutrition
Children with severe protein-energy malnutrition (PEM) are at increased risk of having or developing vitamin A deficiency. Any child with severe malnutrition, showing visible wasting or oedema of both feet, should be given a high dose of vitamin A supplement immediately on diagnosis and referred to the hospital for treatment.
High dose vitamin A supplements should only be administered to children who have not already received vitamin A supplementation within the last four weeks.
Dosing:
— A single high dose of vitamin A supplement, according to age, should be given to children with severe malnutrition immediately on diagnosis.
Table 4: Vitamin A Treatment Schedule During Severe Protein-Energy MalnutritionCHILDREN 0 TO 59 MONTHS OF AGEAgeDoseFrequencyChildren: 0-5 months50,000 IU (15mg)One doseChildren: 6-11 months100,000 IU (30mg)One doseChildren: 12-59 months200,000 IU (60mg)One dose
IX. Assuring sufficient vitamin A through food sources: Dietary diversification
A variety of foods should be eaten every day. Vitamin A can be derived from meat, fish, milk and dairy products and plant foods. Carotenoids, precursors that change into vitamin A in the body, are present in dark green vegetables and orange-coloured fruits and vegetables.
— Vitamin A from animal sources and breast milk is better utilized by the body than carotenoids from plant sources.— Introduce fruit and vegetable home gardens to have better access to a variety of vitamin A-rich foods.— Consume preserved, dried and fortified foods when fresh fruits and vegetables are temporarily unavailable in order to assure a diverse diet year round.
How to prepare foods to increase vitamin A intake:
§ Cut, shred or grind vegetables into small pieces.§ Add a small amount of oil or fat to the meal (½ to 1 teaspoon), preferably canola oil, corn oil or sunflower oil, during mixing and preparation.§ Boil or steam vegetables for a short period of time, preferably with a lid on the pot.§ Avoid long cooking of vegetables under high temperatures.§ Consume foods immediately after preparation, not allowing them to sit for extended periods of time.§ Store fresh fruits and vegetables in a cool and dry place without exposure to sunlight.§ Sun-dry fruits and vegetables as a method of storing and preserving them.
The recommended safe intake levels to meet the vitamin A requirements for infants and children and pregnant and lactating women are indicated in Table 3. Pregnant and lactating women need to consume foods containing sufficient vitamin A for both mother and child.
Table 5: Daily Recommended Safe Intake of Vitamin AINFANTS AND CHILDREN µg RE/day0-6 months 3757-12 months 4001-3 years 4004-6 years 4507-9 years 50010-18 years (male or female) 600ADULTS µg RE/dayPregnant women 800Lactating women 8501 µg RE (Retinol Equivalents) = 3.33 IU vitamin ASource: FAO/WHO, Geneva, 2000
Table 6 indicates the estimated vitamin A concentrations in a variety of common foods.
Table 6: Common Foods and their Estimated Vitamin A ConcentrationsFOOD UNITS µg REMature breast milk (>21 days postpartum)a 500 µg RE/LBeef liver, raw 100g 10,503Carrot, raw 100g 2,813Sweet potato, mashed 100g
http://portal.unesco.org
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