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The Effect of Vitamin A Supplementation on Vision Impairment in Pediatric Patients

Introduction

In low-income countries, vitamin A deficiency (VAD) is a major health concern. 1 This concern is

especially true for children under the age of five, as this population is frequently exposed to respiratory

and parasitic infections that reduce the absorption of vitamin A. 2 Vitamin A is a fat-soluble vitamin that is

necessary for vision as well as many other functions in the body. Children have comparatively high

requirements for vitamin A and the demand for this vitamin only increases during infections. 3 VAD

symptoms include overall slowed growth, an increased vulnerability to infections, and keratinization of

the skin. Those with VAD also tend to suffer from conditions centering around vision impairment such as

night blindness, Bitot’s spots, and progressive blindness due to the impact on the retina, conjunctiva, and

cornea. There is also correlation between VAD and increased morbidity and mortality. 2 Approximately

six out of ten children who become blind will die within one year of complete vision loss. 4 The severity of

VAD is determined by the level of serum retinol. According to the World Health Organization (WHO),

VAD cases that exhibit serum retinol levels of <0.70 µmol/L are considered more severe. 5 VAD is the

main cause of preventable blindness in developing countries. 2

Vitamin A is found naturally in many foods, such as carrots, eggs, fatty fish, kale, milk, and

sweet potatoes. Although some products, including butter and cereals, are also fortified with vitamin A.

Fortified sources of vitamins and minerals are a cost-effective way to improve the daily intake of

nutrients in most areas. In low-income countries, however, the lack of dietary consumption of vitamin A

seems to be associated with food insecurity and absence of general nutritional knowledge rather than

underlying conditions in the population. In rural areas, the mean daily consumption of vitamin A is less

than half of the recommended dietary allowance (RDA) due to a low intake of animal sources of vitamin

A, such as eggs and milk.6 Due to this low intake, vitamin A supplementation (VAS) is recommended in

countries where the mortality rate for children under five years of age surpasses 70 deaths per 1000

births.7 The purpose of this paper is to determine whether the use of vitamin A supplementation reduces

vision impairment in the pediatric population.

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Methods

In order to review research relating to supplemental vitamin A and the effect on vision

impairment in pediatric patients, ProQuest, ScienceDirect, EBSCOhost, and SpringerInk databases were

used as methods in search of literature. The following terms in the search included "vitamin A," “vitamin

A deficiency,” “vitamin A supplementation,” "vision impairment," “children,” “pediatric patients,”

“carotenoids,” and “retinoids.” The measures for this review focused on children between the ages of six

months and ten years, the inclusion of supplemental vitamin A, a focus on vitamin A deficiency, and the

socioeconomic versus individual factors influencing the population. The types of studies included were

cross-sectional, comprehensive, cohort, and descriptive studies. Exclusions included studies prior to 2012,

patients over the age of eighteen years old, and the use of supplemental vitamins other than vitamin A.

Main Findings

Burundi, Middle East Africa

Ruhagaze et al studied the causes of visual impairment in Burundi utilizing the students currently

attending schools for the blind.8 The purpose of this descriptive cross-sectional study was to implement

visual assistance services throughout the country. The students attending three schools for the blind were

examined using a variation of the WHO and Prevention of Blindness (PBL) eye exam records and

interviews of the students. The results were analyzed to locate the participants who were visually

impaired or blind before 16 years of age. In the three schools, there were 117 students who fit this criteria.

109 pupils were blind or severely visually impaired. The known causes of blindness were cornea

pathology, lens pathology, uveal lesions, and optic nerve lesions. The reason for the vision loss for many

of the students, however, was unknown. The known causes show the need for preventive public health

strategies. The geographic demography of the students at the schools for the blind also shows the

importance for programs in the communities to help recognize and subsequently refer children who are in

need of these public services. The results of this study also concluded that VAD blindness has not been

identified as a problem in Burundi. This is possibly due to the VAS in children ranging from 6 months to

5 years of age during a public health service called Mother and Child Health Weeks (MCHW) that occurs
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in Burundi twice a year. This is the first study conducted in Burundi and it should be noted that these

schools only represent a small part of the country’s population. The schools have a limited capacity and

could not possibly be an accurate representation of the entire country. However, the results of this study

have positive implications for the advocacy of general VAS for children to prevent visual impairment as

evidenced by the implied success of the MCHW.

Varamin District, Iran

In a descriptive cross-sectional study of eye care facilities in the Varamin District of Iran, Katibeh

et al surveyed the prevalence of preventable blindness. 9 The purpose of the study was to identify the

provisions and pitfalls of health services in this district. The WHO analytical health system framework

was utilized by the researchers to investigate the functionality of various services using questionnaires

delivered by the team. There are 16 ophthalmic clinics and two hospitals that perform cataract surgery.

For the entirety of the Varamin population, there are ten ophthalmologists, two ophthalmic nurses, and

five optometrists. The leading cause of blindness was cataracts, although there was high availability for

insurance-covered surgeries. Lack of knowledge was a major concern. None of the clinics had an

applicable blindness prevention plan or written referral channels. Of the 16 clinics, only one referred

diabetic patients for eye examinations. For prevention of pediatric blindness, there were few options.

These included chemoprophylaxis, school vision tests, measles immunization, and VAS. This study

confirmed the need for improved cooperation between eye care services and the general health services.

The prevention of blindness and more integration of health education needs to be implemented into the

community and service industry as well. Overall, the health care system in place needs to be upgraded to

allow higher quality of comprehensive eye care. Pediatric supplementation of vitamin A was given free to

any children under the age of two years old, if they were brought to the clinic for vaccination or health

care service. VAS, in this district, began 15 days after birth and is provided until two years of age is

reached. VAS was also given to any child with malnutrition or diarrhea. In the Varamin District, pediatric

patients do receive medicines related to eye health and the prevention of childhood blindness. In Iran, the
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statistics of blind children due to malnutrition or corneal impairment is low which shows positive

correlation to the measures being taken to prevent pediatric blindness.

Addis Ababa, Ethiopia

Bezabih et al studied the prevalence and factors of pediatric visual impairment in Ethiopia. 10

Using a cross-sectional study design, four schools in Addis Ababa were selected at random. Of these four

schools, 804 pupils were designated to participate using a simple random sampling method. Two types of

logistic regression, bivariable and multivariable, were then conducted to determine the value for

association. A significant association was found at a p-value of 0.05. Of the original 804 pupils, only 718

students contributed answers to the study. 7.24% of the children had visual impairment, while only 3.34%

had severe impairments. Variables to these percentages included sex, age groups, type of school, amount

of television watched, viewing distance from television, cell phone exposure, and occurrence of medical

visits. Many of the visually impaired students had low vision, but there were not many cases of severe

visual impairment. The lack of knowledge about visual impairment and an increase in eye health services

was hypothesized to possibly reduce the frequency of impairments. The main cause of optical impairment

was found to be VAD. This study implies that an increase in VAS could be associated with lower levels

of vision impairment when related to VAD complications.

Dhaka, Bangladesh

Approximately 2% of pediatric death under the age of five can be associated with VAD. 11

Regardless of this information, there is a lack of scientific-based evidence for the supplementation of

vitamin A. Mostafa et al conducted a study to determine the variables affecting the lack of data for VAS.

The researchers collected data from the Diarrheal Diseases Surveillance System (DDSS) for children aged

1 to 5 years of age who were admitted to the Dhaka Hospital of the International Center for Diarrheal

Disease Research in Bangladesh from 1996 to 2014. From this data, a logistic regression model was

created to recognize the factors that were associated with non-compliance to VAS. The association

strength was calculated using adjusted odds ratios (aORs) and their confidence intervals within 95%.

From the collected data, the sample consisted of 8649 pediatric patients with a mean age of was 25.2 ±
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12.8 months. Of these patients, approximately 40% were female. VAS had been supplied to around 68%

of these children within 6 months. In the analytics, children older than 24 months, having an illiterate

parent(s), coming from mid- to low-income percentiles, and lack of measles vaccinations were found to

be more likely to not have received VAS in the six-month window. An increase in VAS from 61% to

76% over the duration of data collected was also observed. Though there is an increase in the prevalence

of VAS, it is approximated that one-third of children are still lacking appropriate vitamin A levels. The

implications of further reaching VAS could lessen childhood morbidity and mortality rates. The

conclusions also suggest that vision problems, such as night blindness and xerophthalmia, could be

decreased by an increase in VAS.

Discussion and Conclusion

Based on the studies outlined above, more studies are needed because it is not definitively clear if

vitamin A supplementation would reduce the prevalence of vision impairment in pediatric patients. In

2013, Ruhagaze et al studied the causes of visual impairment in Burundi but there was only circumstantial

evidence to infer that VAS could effectively reduce the rates of optical impairment. In 2015, Katibeh et al

established the prevalence of preventable blindness in Iran, but the evidence for reduction of impairment

was not evident on the effects of VAS. In 2017, Bezabih et al studied pediatric visual impairment in

Ethiopia where the main cause of impairment was found to be associated with VAD. VAS treatments

were implied to lower the rates of optical problems but were in association with rates of VAD. In 2019,

Mostafa et al gathered data in Bangladesh from 1996 to 2014 to conclude the reasoning for the lack of

VAS compliance. The lack of compliance to VAS was the primary focus of the study, and there was no

evidence shown for a reduction in the rates of vision impairment. These studies show an abundance of

circumstantial evidence for VAS reducing the rates of visual impairment in children. However, there is no

scientific evidence to clearly state whether VAS will reduce optical impairment in pediatric patients.
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