Regular vitamin A supplementation: prioritizing the youngest children

Should we prioritise children 6-23 months of age for vitamin A supplementation? Case study of West and Central Africa

Background

Vitamin A (VA) supplementation has been associated with reductions of all-cause child mortality. Child mortality amenable to VA, particularly related to infectious diseases, may be age dependent; hence, the beneficial effect of VA supplementation may differ between younger and older children. We aimed to estimate the all-cause child mortality disaggregated by younger and older than 2 years of age and estimate the contribution of VA supplementation in preventing child death in West and Central Africa.

Methods

Using the most recent (post-2010) cross-sectional Demographic and Health Surveys and Multiple Indicator Cluster Surveys, we analysed child-level data (n=187 651) from 20 West and Central African countries. Age-specific (all-cause) mortality rates were estimated using survival analyses. Age-specific VA supplementation coverage was linked with the age-specific all-cause child mortality to estimate the contribution of the supplementation in averting child death.

Results

The cost per averted child death was also estimated using an average cost of US$1.2/child and VA supplementation coverage which ranged from 14% in Cote d'Ivoire to 81% in the Gambia. About 75% of the under-5 mortality occurred in the first 2 years of life. The share of excess (all-cause) mortality averted by VA supplementation was significantly higher in the first 2 years of life. A mean reduction of 7.1 deaths/1000 live births was estimated for children 6-23 months, compared to a reduction of 2.5 deaths/1000 live births for older children (24-59 months). The mean cost/averted child death for the 20 countries was 2.8 times lower for the 6-23 than the 24-59 months age group.

Conclusion

Prioritising VA supplementation for children in the first 2 years of life could be more cost-effective than when implemented among 6-59 months of age.

Effects of Food-Based Approaches on Vitamin A Status of Women and Children: A Systematic Review

Vitamin A deficiency (VAD) increases risk for morbidity and mortality. Food-based approaches offer one strategy to improve vitamin A status. This systematic review assessed evidence of the effects of food-based approaches on the vitamin A status of women and children under 5 y. VAD was defined as clinical ocular symptoms, such as loss of vision, and/or retinol plasma or serum concentration <0.70 μmol/L. Searches on food-based approaches to improve vitamin A status were conducted for the period 2011-2022 on PubMed, CINHAL, Web of Science, and Google Scholar using PRISMA guidelines. English-language publications were included. Case studies, unpublished dissertations, and non-peer-reviewed studies were excluded. This review comprises 24 of 27,322 identified studies; 23 included studies focused on provitamin A carotenoids. There were 17,214 participants across the 24 studies with sample sizes ranging from 8 to 3571 individuals. Intervention studies spanned from 3 wk to 2 y. Fifteen (63%) studies were randomized control trials, 7 were cross-sectional, and 2 were longitudinal studies. Most studies (N = 21) used biochemical measurements, for example, serum retinol, to assess vitamin A status; other studies used clinical symptoms (for example, xerophtalmia) or dietary intake. Thirteen (54%) studies reported a statistically significant effect of food-based interventions (N = 8) or an association of diet (N = 5) on vitamin A status. This systematic review indicated that some food-based interventions improved vitamin A status, thus offering a safe and effective delivery mechanism for vitamin A. There appeared to be significant association between vitamin A status and consumption of foods with high concentrations of preformed vitamin A and provitamin A carotenoids. Differences across studies in regard to the period of evaluation, food approaches used, and statistical power may explain the lack of effectiveness of food-based approaches on vitamin A status in some studies.

Evaluating equity dimensions of infant and child vitamin A supplementation programmes using Demographic and Health Surveys from 49 countries

OBJECTIVES

Vitamin A deficiency affects an estimated 29% of all children under 5 years of age in low/middle-income countries, contributing to child mortality and exacerbating severity of infections. Biannual vitamin A supplementation (VAS) for children aged 6-59 months can be a low-cost intervention to meet vitamin A needs. This study aimed to present a framework for evaluating the equity dimensions of national VAS programmes according to determinants known to affect child nutrition and assist programming by highlighting geographical variation in coverage.

METHODS

We used open-source data from the Demographic and Health Survey for 49 countries to identify differences in VAS coverage between subpopulations characterised by various immediate, underlying and enabling determinants of vitamin A status and geographically. This included recent consumption of vitamin A-rich foods, access to health systems and services, administrative region of the country, place of residence (rural vs urban), socioeconomic position, caregiver educational attainment and caregiver empowerment.

RESULTS

Children who did not recently consume vitamin A-rich foods and who had poorer access to health systems and services were less likely to receive VAS in most countries despite potentially having a greater vitamin A need. Differences in coverage were also observed when disaggregated by administrative regions (88% of countries) and urban versus rural residence (35% of countries). Differences in vitamin A coverage between subpopulations characterised by other determinants of vitamin A status varied considerably between countries.

CONCLUSION

VAS programmes are unable to reach all eligible infants and children, and subpopulation differences in VAS coverage characterised by various determinants of vitamin A status suggest that VAS programmes may not be operating equitably in many countries.

Age Distribution of All-Cause Mortality Among Children Younger Than 5 Years in Low- and Middle-Income Countries

Importance

Coverage of essential child health and nutrition interventions in low- and middle-income countries remains suboptimal. Adverse exposures, such as undernutrition and infections, are particularly harmful during the 1000 days from conception until 2 years of age.

Objective

To investigate whether deaths in children younger than 5 years-which also reflect adverse exposures faced by children more broadly-are concentrated in the first 2 years after birth.

Design, Setting, and Participants

This cross-sectional study used a synthetic cohort probability method with Demographic and Health Surveys and Multiple Indicator Cluster Surveys from 77 low- and middle-income countries, with the earliest survey starting data collection in March 2010 and the most recent survey ending data collection in December 2019. Participants included 2 827 515 children who were younger than 5 years at any point 10 years before survey. Data were analyzed from March 11 to 21, 2022.

Main Outcomes and Measures

Share of deaths among children younger than 5 years occurring before 1 month, at 1 to 23 months, and at 24 to 59 months of age.

Results

Among the 2 827 515 children included in the analysis, 81.5% (95% CI, 81.0%-82.0%) of deaths occurred in the first 2 years after birth ranging from 63.7% (95% CI, 61.6%-65.7%) in Niger to 97.8% (95% CI, 85.9%-99.7%) in Albania. An estimated 18.5% (95% CI, 18.0%-19.0%) of child deaths occurred at 24 to 59 months of age. Countries with higher mortality rates among children younger than 5 years had a lower share of deaths occurring in the neonatal period.

Conclusions and Relevance

In this sample of 77 low- and middle-income countries, a large majority of deaths among children younger than 5 years occurred before 2 years of age in all countries among boys and girls and in households with the worst and best living standards. Research has highlighted perinatal complications, infections, and undernutrition as primary causes of death among children younger than 5 years. Therefore, coverage of interventions to reduce these adverse exposures should be ensured during pregnancy and the first 2 years after birth, which is also a crucial period for human development.

Estimated effect of vitamin A supplementation on anaemia and anthropometric failure of Indian children

BACKGROUND

India has an unacceptably high burden of vitamin A deficiency (VAD) among children aged 6-59 months. To mitigate VAD and its adverse effects on child health, the Indian government runs a nationwide vitamin A supplementation (VAS) programme. However, the effect of VAS in reducing child morbidity and mortality remains inconclusive and has been debated globally. In this paper, we estimate the effect of VAS on two indicators of child nutrition-anaemia (categorized into any anaemia, and mild/moderate anaemia) and anthropometric failure (categorized into stunting, wasting, and underweight) among children aged 6-59 months.

METHODS

Using the nationally representative 2015-2016 National Family Health Survey data set from India, we set up a quasi-experimental study design and estimated household and mother fixed-effects of VAS on select types of child anaemia and anthropometric failure.

RESULTS

Findings from both the household fixed-effects and mother fixed-effects analysis showed that VAS does not influence any types of childhood anaemia and anthropometric failure in India. We discussed the findings considering existing literature and possible limitations of the study.

CONCLUSIONS

The infirm effect of Vitamin A on anaemia and anthropometric failure is probably indicative of targeted VAS intervention, as opposed to a universal VAS programme.

IMPACT

Effects of vitamin A supplementation (VAS) in treating child morbidity and mortality remain inconclusive, which calls for further rigorous studies. This study set up a quasi-experimental research design and estimated the null effect of VAS on child anaemia and childhood anthropometric failure. While the cautious interpretation of findings is urged, this study reliably supports targeted intervention of VAS, instead of the universal VAS programme. The use of nationally representative data and robust research protocol are the primary strengths of this study.

Consumption of Vitamin-A-Rich Foods and Vitamin A Supplementation for Children under Two Years Old in 51 Low- and Middle-Income Countries

Vitamin A supplementation for children 6-59 months old is an important intervention that boosts immune function, especially where children do not consume enough vitamin-A-rich foods. However, the low coverage of vitamin A supplementation is a persistent problem in low- and middle-income countries. We first estimated the percentage of children 6-23 months old receiving the minimum dietary diversity, vitamin-A-rich foods, and vitamin A supplementation, and second, the difference in the percentage receiving vitamin A supplementation between children 6-23 months old and children 24-59 months old using nationally representative cross-sectional household surveys, namely, the Demographic and Health Surveys, conducted from 2010 to 2019 in 51 low- and middle-income countries. Overall, 22% (95% CI: 22, 23) of children received the minimum dietary diversity, 55% (95% CI: 54, 55) received vitamin-A-rich foods, 59% (95% CI: 58, 59) received vitamin A supplementation, and 78% (95% CI: 78, 79) received either vitamin-A-rich foods or supplementation. A wide variation across countries was observed; for example, the percentage of children that received either vitamin-A-rich foods or supplementation ranged from 53% (95% CI: 49, 57) in Guinea to 96% (95% CI: 95, 97) in Burundi. The coverage of vitamin A supplementation should be improved, especially for children 6-23 months old, in most countries, particularly where the consumption of vitamin-A-rich foods is inadequate.