VITAMIN A PROGRAM IN INDIA AND ITS IMPLEMENTATION

goi vitamin a program and details about thevita A program history and implementation

1. VIT A PROGRAM

2. Vitamin A is an essential fat-soluble micronutrient required for normal growth and development, maintenance of healthy mucosal membranes, reproductive health, immunity , vision, especially for dark adaptation.

3. WHO defines vitamin A deficiency as a significant public health problem, when the prevalence of night blindness is >1% in children between 2-5 years and/or the serum retinol levels are below 20 µg/ dL in £20% of children aged 6-59 months . The recent Comprehensive National Nutrition Survey (CNNS; 2016-18) conducted in 30 states has shown the prevalence of vitamin A deficiency (VAD; defined as serum retinol <20 µg/ dL ) in 1-4 year old children as 15.7% (95% CI 15.2%, 16.3%), after adjusting for inflammation (objectively measured by elevated levels of C-reactive protein). There was no urban/rural or sex differences in prevalence. The VAD prevalence was below 20% at the National level, irrespective of whether the children had received MDVAS in the past 6 months This definitely proved the point that vitamin A supplementation under programmatic circumstances had negligible role in increasing serum retinol concentration.

4. CONTRIBUTING FACTORS Poverty and ignorance, mainly due to low literacy particularly among women . Inadequate intakes of vitamin A in women during pregnancy and lactation, increase the chances of VAD in the offspring. Consumption of inadequate amounts of the vitamin in diets among all the age groups. On the average, diets of young children in the rural areas are woefully inadequate in foods providing β-carotene/retinol. The consumption of animal sources such as milk and eggs that provide preformed vitamin A is very low. As a result, the mean daily consumption of vitamin A is less than half of the recommended dietary allowance (RDA), and more than a third of the children of 1-6 yr of age consume much below 25 per cent RDA of vitamin A.

5. CONTRIBUTING FACTORS The intestinal conversion ratio of dietary carotenoids to retinol is currently reported to be 12:1. The efficiency of conversion of β-carotene to retinol is only about a half as compared to that thought so far. The diets which are primarily based on β-carotene providing vegetables and fruits are unlikely to provide the required amounts of vitamin A in communities, subsisting on inadequate diets.

6. CONTRIBUTING FACTORS Avoidance of foods rich in β-carotene such as papaya during pregnancy Discarding colostrum immediately after childbirth, due to superstitions and general lack of awareness in the community about the nutritional needs also contribute to poor vitamin A status from very young age . Indian preschool children are exposed to frequent respiratory infections and diarrhoea and parasitic infestations. Repeated infections reduce the absorption of vitamin A, aggravating further the already poor nutritional status of the children in rural communities .

7. In 1994, under the National Child Survival and Safe Motherhood (CSSM) Programme , the NPPNB due to VAD was modified keeping in view of the vulnerability of VA deficiency in young children . The age group of eligible children for coverage was restricted to 9 to 36 months of age. Accordingly , each child was to receive five doses of VA before her/his 3 rd  birthday (children age 6-11 months, 1 dose of 100,000 IU of VA and in age 12- 36 months of age one dose of 200,000 IU of VA every six months). In view of operational feasibility, the administration of first dose of VA was linked to measles immunization.

8. In 2006, the age group of eligible children was revised as 6-59 months. This was done after reconsidering the recommendations of WHO, UNICEF and Ministry of Women and Child Development. This was despite the evidence that clinical VAD was limited to a few isolated geographical pockets in the country. A National survey conducted by Indian Council of Medical Research (ICMR) in 2001, covering 16 districts in all five regions of the country showed that only three out of 16 districts had prevalence of Bitot spots (BS) of 0.5 per cent and more.

9. Vitamin A deficiency (VAD) continues to be a major nutritional problem of public health concern in India, despite the implementation of a programme for vitamin A supplementation for over four decades. Although the incidence of clinical VAD in India has declined significantly over the period of time, the highest proportion of the world’s VAD children still lives in India The proportion of rural preschool children in India with Bitot’s spots, an objective clinical sign of VAD is reported to be over 0.5%, making VAD a public health problem A similar pattern of prevalence of sub-clinical VAD (serum retinol ≤ 0.70 µ mol /L or ≤ 20 µg/ dL ) is also observed and confirms VAD to be a severe public health problem (≥ 20%) in India .

10. In 1970, the Government of India launched the “National program for prophylaxis against blindness in children due to vitamin A deficiency” targeting children 1–5 years Subsequently, the VAS programme was revisited in 1991 by the Indian experts in the context of emerging evidence of the impact of VAS on child mortality and an India study on seroconversion of measles vaccine by the NIN The revised VAS programme included infants 6–11 months and was renamed as “Management of Vitamin A deficiency Programme ”. In the early period of implementation, taking into consideration the supply of vitamin A solution and cost, the policy accorded a higher priority to administer VAS to the most vulnerable children aged 9–36 months.

11. In 2006, with increased prevalence of VAD in 36–59 months children and no constraint on the supply of vitamin A solution, the Government of India expanded the target age group to meet the 1991 policy guidelines to 6–59 months . The VAS is in operation in India as well as in more than 70 countries around the world and is recognised to be one of the most effective public health interventions ever undertaken . Taking into consideration, the need for improving the coverage of six monthly administration of VAS In India, a biannual VAS strategy was piloted and scaled up in India .

12.  Retinol transport in the blood requires two specific proteins, retinol binding protein (RBP) and transthyretin (TTR). Synthesis of RBP is dependent on child's protein, retinol, iron and zinc status. Zinc status influences several aspects of vitamin A metabolism including its absorption, transport and utilization. Zinc deficiency impairs synthesis of RBP which affects retinol transport from liver to the blood and other tissues .

13. Iron deficiency affects vitamin A metabolism leading to reduction in serum retinol and an increase in hepatic retinol and retinyl esters. The mobilization of vitamin A from the liver is hampered in protein calorie malnutrition, dietary protein is required to mobilize liver reserves of vitamin A into the blood stream and increased protein intake results in greater vitamin A requirement. Plasma retinol is reduced by clinical and subclinical infection

14. POSSIBLE ADVERSE EFFECTS: WHEN NO DEF OF VIT A Bulging fontanel : Nearly12 per cent of young children when administered 50,000 IU of VA developed bulging fontanel . Significant proportion of brain development takes place before three years of age. In India, as per the National Family Health Survey (NFHS)- 3 ,  48 per cent of children suffer from undernutrition (below minus 2 SD). Subjecting these malnourished under three children to repeated episodes of increased intra-cranial tension could contribute to retarded brain development. There is lack of scientific evidence on the long term ill effects of these repeated episodes of raised intra-cranial tension on brain development of intrauterine growth retarded children who start their lives with psychomotor deficits.

15. POSSIBLE ADVERSE EFFECTS- WHEN NO DEF OF VIT A Vitamin D antagonism : Animal studies suggest that vitamin A is an antagonist of vitamin D action. Massive doses of vitamin A intensify the severity of bone demineralization and inhibit the ability of vitamin D to prevent such demineralization. Increasing amounts of retinyl acetate produce progressive and significant decrease in total bone ash and increase in epiphyseal plate width . Increasing the levels of retinyl acetate abrogates the ability of vitamin D to elevate the level of serum calcium Considering , the current epidemic prevalence of vitamin D deficiency in the country, interventions potentially detrimental for bone health (massive dose VAS) are best avoided.

16. POSSIBLE ADVERSE EFFECTS- WHEN NO DEF OF VIT A Potential zinc deficiency : There is a possibility that zinc deficiency, which is already present in these children, could be aggravated by massive doses of vitamin A. Zinc is required for growth of children. Under these circumstances, the administration of massive doses of vitamin A to children who may be deficient in multiple vitamins including vitamin D and zinc could aggravate growth retardation. The potential role of massive-dose vitamin A prophylaxis in the persistence of stunting in poor children requires serious consideration . Risk of acute respiratory infection : Vitamin A administration has been associated with a significant increase in rate of pneumonia in well nourished children who received 10,000 IU of supplements weekly.

17. REVIEW

18. 1, Which of the following is not a characteristic of the proximodistal principle of development? A. Growth proceeds from the center of the body to the periphery. B. Growth proceeds from the head to the toes. C. Growth proceeds in a sequential fashion. D. Growth proceeds from the general to the specific. 2, Pinky can sit on small chair; walks up stairs with 1 hand held; makes tower of 4 cubes; and can name pictures. What is the expected age of Pinky? A. 12 months B. 15 months C. 18 months D. 24 months E. 30 months   3. Although 5% of preschool children will stutter, it will resolve in 80% of those children by age of A . 6 years B . 7 years C . 8 years D . 9 years E . 10 years

19. 4. The upper-to-lower body segment ratio equals approximately 1.7 at birth, and 1.0 after A. 5 yr B. 7yr C. 9 yr D. 11yr E. 13 yr Explanation: The U/L ratio equals approximately 1.7 at birth, 1.3 at 3 year, and 1.0 after 7 year. Higher U/L ratios are characteristic of short-limb dwarfism, as occurs with Turner syndrome or bone disorders, whereas lower ratios suggest hypogonadism or Marfan syndrome . 5. Which of the following is classified as a problem related to poor attention in a child with attention deficit hyperactivity disorder (ADHD)? A. Runs about excessively in situations in which it is inappropriate B . Overlooks or misses details, with inaccurate work C. Difficulty playing or engaging in leisure activities quietly D. Leaves seat in classroom or in other situations in which remaining seated is expected E. Fidgets with hands or feet or squirms in seat A child with ADHD often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate). All other distracters are related to problems of hyperactivity/impulsivity.

20. 6. A 3-year-old boy is brought to you by his parents because of poor social communications. He communicates by reaching partner`s hand and placing it on the desired objects. Protests are demonstrated through pushing hands. He plays functionally with toys when seated and used eye gaze appropriately during cause-and-effect play, but otherwise eye gaze is absent. He appears to be nonengaged and responds inconsistently to his name. He has repetitive finger movements, body rocking and lunging, and echoing words immediately after parents are said. He has a pattern of repeated turning light switches on and off, and opening and closing doors. Of the following, the MOST likely diagnosis is A . social communication disorders B. language disorders C . Autism spectrum disorders D . hearing loss E . social anxiety Children with language disorders do not have associated restricted and repetitive behavior or atypical use of language. The diagnosis of social communication disorder is also distinguished from ASD by the lack of restrictive and repetitive behaviors. Children with hearing loss may present with some “red flags” for ASD, such as poor response to name. However, they typically develop nonverbal communication and play skills as expected and do not have stereotyped or restricted behavior patterns. Children with social anxiety may present with some symptoms suggestive of ASD. Shy children may have reduced eye contact and social initiation. However, they typically have preserved social interest and insight and will not exhibit high levels of stereotyped behaviors.

21. 7. At which of the following ages onset of stuttering is typically occurring? A . Below 2 yr B . 2-4 yr C . 5-6 yr D . 7-8 yr E . Above 12 yr Seldom does a child begin stuttering before 2 yr of age or after 12 yr ; in fact, the mean age of onset is 2-4 yr , and most children stop stuttering within 4 yr of onset 8. What is the FIRST clotting factor affected by vitamin K deficiency? A . VII B . VIII C . IX D . X E . ΧΙΙΙ Factor VII has the shortest half-life of the coagulation factors and is the first to be affected by vitamin K deficiency, but isolated factor VII deficiency does not affect the partial thromboplastin time.

22. 9. Which of the following is considered as an earlier clinical feature of vitamin A deficiency? A . Xerophthalmia B . Bitôt spots C . Delayed dark adaptation D . Keratomalacia E . Corneal ulceration An earlier symptom of vitamin A deficiency is delayed dark adaptation, as a result of reduced resynthesis of rhodopsin; this may progress to night blindness 10. Which of the following is a feature of mild dehydration? A . Thirst B . Tachycardia C . Lethargy D . Sunken fontanel E . Decreased tears (A) Mild dehydration (10% in an infant; >6% in an older child or adult): Normal or increased pulse; decreased urine output; thirsty; normal physical findings

23. 11. Which of the following is a clue to severe dehydration? A . Cold and mottled skin B. Oliguria C. Sunken eyes and fontanel D. Dry mucous membranes E Irritability (A) Severe dehydration (>10% in an infant; >6% in an older child or adult):Peripheral pulses either rapid and weak or absent; decreased blood pressure; no urine output; very sunken eyes and fontanel; no tears; parched mucous membranes; delayed elasticity (poor skin turgor); very delayed capillary refill (>3 sec); cold and mottled; limp, depressed consciousness.

24. 12 A bottle fed 18-month-old boy presents with history of vomiting and diarrhea. Examination shows severe degree of dehydration; serum Na+ (126 mEq /L), serum K+ (4.5mEq/L), pH (7.25), HCO3 (14 mEq /L), and PCO2 30 mm Hg; he received IV fluid therapy and after 12 hours, the patient became confused and agitated. Serum electrolytes were done revealing serum Na+ (145 mEq /L), serum K+ (3.7mEq/L), serum Ca + (8.7 mg/dl), and blood glucose (98 mg/dl). Of the following, the MOST likely cause of his deterioration is A . cerebral edema B . central pontine myelinolysis C. arrhythmias D . brain herniation E . intracranial hemorrhage (B) With all causes of hyponatremia , it is important to avoid overly rapid correction, which may cause central pontine myelinolysis (CPM). This syndrome, which occurs within several days of rapid correction of hyponatremia , produces neurologic symptoms, including confusion, agitation, flaccid or spastic quadriparesis , and death. There are usually characteristic pathologic and radiologic changes in the brain, especially in the pons, but extrapontine lesions are quite common and may cause additional symptoms. Despite severe symptoms, full recovery does occur in some patients. Even though CPM is rare in pediatric patients, it is advisable to avoid correcting the serum [Na+] by >10 mEq /L/24 hr or >18 mEq /L/48 hr

25. 13 A 10-month-old infant presents with frequent loose bowel motions and excessive thirst over the past 24 hours. Examination shows restlessness, sunken eyes, and skin pinch goes back slowly. Of the following, the MOST appropriate therapy is A . IV normal saline (0.9% NaCl ) B . IV ½ normal saline + 10 mEq /L KCl C . IV D5 ½ NS + 30 mEq /L sodium bicarbonate D . Standard oral rehydration solution (ORS) E . Low osmolarity ORS (E) The World Health Organization defines some dehydration as the presence of two or more of the following signs: restlessness/irritability, sunken eyes, drinks eagerly, thirsty, and skin pinch goes back slowly. Infants and children with some dehydration need rehydration therapy with ORS: ORS, 50-100 mL/kg over 3-4 hr. Continue breast feeding. After 4 hr , give food every 3-4 hr for children who normally receive solid foods. Item D is old ORS recommended in 1976 and item E is new ORS recommended in July, 2001

26. 14. A 9-month-old infant evaluated for failure to thrive; history reveals frequent vomiting and arching his back during feeding with recurrent hospital visits for wheezing and shortness of breath. Of the following, the MOST likely diagnosis is A . intuscessption B . gastroesophageal reflux disease C . asthma D . H-type esophageal fistula E . achalasia (B) Most of the common clinical manifestations of esophageal disease can signify the presence of GERD and are generally thought to be mediated by the pathogenesis involving acid GER. Infantile reflux manifests more often with regurgitation (especially postprandially ), signs of esophagitis (irritability, arching, choking, gagging, feeding aversion), and resulting failure to thrive; symptoms resolve spontaneously in the majority of infants by 12-24 mo. Older children can have regurgitation during the preschool years; this complaint diminishes somewhat as children age, and complaints of abdominal and chest pain supervene in later childhood and adolescence. Occasional children present with food refusal or neck contortions (arching, turning of head) designated Sandifer syndrome

27. 15. Which of following micronutrients should not be given in the stabilization phase of acute severe malnutrition? A. Zinc B. Vitamin A C. Iron D. Copper E. Folic acid (C) Iron is given in the maintenance phase of treatment . 16. At which age vitamin K–dependent coagulation factors reach adult ranges? A. End of first week of life B. End of neonatal period C. At 4 months of life D. At 6 months of life E . At end of first year of life (D) Plasma levels of the vitamin K–dependent coagulation factors (II, VII, IX, X, protein C, protein S) and antithrombin are low at birth and do not reach adult ranges until approximately 6 mo of age

28. 17. In which of the following conditions with short stature, bone age is normal? A. Familial short stature B. Constitutional delay C. Hypothyroidism D. Undernutrition E. Celiac disease (A) In familial short stature the bone age is normal (comparable to chronological age), whereas constitutional delay, endocrinologic short stature, and undernutrition may be associated with delay in bone age comparable to the height age . 18.   Children should be measured lying down until which age? 9 months 12 months 18 months 24 months 30 months The convention is to measure children lying down until the age of 2 years when they can generally cooperate with a height measurement. Recumbent length is longer than standing height (due to compression of the spine on standing) so it is important that health professionals are consistent in their measurements.

29. 19. Question 1. Which one of the following babies with IUGR (intrauterine growth retardation) has the best prognosis for growth? ( a) A baby with a genetic syndrome (b) A baby whose birth weight is <10th centile and length on the 25th centile ( c) A baby whose weight, length and head circumference at birth are < 10th centile ( d) A baby born to short parents who are themselves on the 2nd centile ( e) A baby with features of TORCH Baby b's weight but not his length was affected by intrauterine growth retardation. The adverse influences therefore occurred towards the end of the pregnancy and the prognosis for growth is good. All of baby c's growth parameters are affected indicating that the adverse conditions were present early on in the pregnancy and so growth potential is likely to be reduced. The other conditions are all associated with short stature.

30. 20. The term global developmental delay implies that all four developmental areas are affected. However it is not unusual for one developmental area to be spared. Which one? (a) Speech and language (b) Fine motor (c) Gross motor (d) Social skills C The other three areas are more reflective of intellectual abilities and so delay in those areas are more concerning. A child with significant learning disabilities may still attain their gross motor milestones at a normal age.