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Exploring a spatial template for targetted supplementation of vitamin A in under-5 Indian children

Pediatric Research volume 93, pages 1460–1462 (2023)Cite this article

The World Health Organization (WHO) advocates the practice of universal vitamin A supplementation (VAS) among under-5 children in countries where vitamin A deficiency (VAD) is a serious public health problem (defined as night blindness prevalence ≥1% among children aged 24–59 months, or low serum retinol prevalence ≥20% in children aged 6–59 months).1 Under this strategy, high doses of prophylactic vitamin A are periodically provided to all eligible children (total nine doses with a gap of 6 months between two consecutive doses) to address VAD and the consequent risks to child health.1 Due to high burden of childhood VAD in the past, India has been historically regarded as a ‘priority’ nation for implementation of universal VAS. In alignment with WHO recommendation, there are standing guidelines from the Government of India for providing VAS in all under-5 Indian children (with the first dose usually provided at 9 months of age, i.e. at the time of measles vaccination).2 However, a considerable decline in the burden of VAD and the attendant health risks in India over the years have led to rising scepticism about whether continuation of the universal VAS programme is justified.3,4 For instance, the national prevalence of VAD (defined as serum retinol concentrations <20 µg/dL, adjusted for inflammation) among children younger than 5 years was recently estimated to be 15.7% with significant interstate differences,3 thereby raising questions on the relevance and validity of universal VAS in contemporary India.3,5 There are also apprehensions that this dated practice of administering massive vitamin A doses indiscriminately to all children in the eligible age range may now do ‘more harm than good’ by increasing the risk of hypervitaminosis A, especially with the concurrent spurt in vitamin A-fortified common food items (e.g. edible oil and milk).3,4 Such concerns have also been voiced in other nations.6 Further, the benefits of universal VAS on child health and survival have supposedly diminished over the years and are no longer applicable, thereby calling for a policy realignment in favour of targetted VAS.3,4,7

With this background, the study by Rai that was published recently in Pediatric Research is a very timely effort.8 In that study, Rai aimed to estimate the effect of VAS (as an explanatory variable) on two important outcomes of childhood undernutrition in India, namely, anaemia and anthropometric failure (including wasting, stunting, and underweight). For that purpose, nationally representative cross-sectional data collected in 2015–2016 during the fourth round of National Family Health Survey (NFHS-4) was adapted to a quasi-experimental fixed-effects study design framework, wherein household- as well as mother-fixed effects of VAS on the stated undernutrition indicators were evaluated. Findings from both the models (i.e. household- and mother-fixed effects approaches) showed that VAS had no effect on childhood anaemia or anthropometric failure in India. Consequently, it was inferred that universal VAS may not be effective for mitigating childhood diseases and nutritional problems of interest in India and that targetted VAS may be a more appropriate solution instead.8

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Data availability

The National Family Health Survey (NFHS-4) data used in this work are available in the public domain at http://rchiips.org/nfhs/districtfactsheet_NFHS-4.shtml. Besides, the literature that forms the basis of this commentary are provided in the list of references. No other data sources were utilized in this work.

References

  1. World Health Organization. Guideline: Vitamin A Supplementation in Infants and Children 6–59 Months of Age (World Health Organization, 2011).

  2. Child Health Division. Vitamin A and IFA supplementation – Regarding No.Z.28020/30/2003-CH (Child Health Division, Ministry of Health and Family Welfare, Government of India, 2006).

  3. Reddy, G. B. et al. Vitamin A deficiency among children younger than 5 y in India: an analysis of national data sets to reflect on the need for vitamin A supplementation. Am. J. Clin. Nutr. 113, 939–947 (2021).

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Authors and Affiliations

  1. Haematology Division, ICMR–Regional Medical Research Centre, North East Region, Dibrugarh, Assam, India

    Kaustubh Bora

  2. DHR–Model Rural Health Research Unit (MRHRU), Chabua, Dibrugarh, Assam, India

    Trishna Bora

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  1. Kaustubh Bora
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  2. Trishna Bora
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K.B. conceived the manuscript, analysed the data and drafted the paper. T.B. contributed to data management and analysis. Both authors revised the manuscript critically for intellectual content and approved the final version.

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Correspondence to Kaustubh Bora.

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Bora, K., Bora, T. Exploring a spatial template for targetted supplementation of vitamin A in under-5 Indian children. Pediatr Res 93, 1460–1462 (2023). https://doi.org/10.1038/s41390-022-02327-x

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