The WHO has estimated that 19 million (15.3%) pregnant women and 190 million (33.3%) of preschool aged children in the world’s poorest countries are vitamin A deficient. [1, 2] In Bangladesh, one in five preschool-age children are vitamin A deficient. This deficiency contributes to morbidity and mortality from severe infections and is the main cause of blindness in undernourished children. [3]

This innovation was provided as antenatal and newborn vitamin A supplementation in two large cluster-randomized controlled trials to reduce maternal and infant mortality in the JiVitA project site from 2001-2017. [3, 4, 5] The interventions included weekly supplementation of vitamin A capsules or placebo to pregnant mothers from the first trimester through 12 weeks after delivery and/or a single dose of vitamin A (50,000 IU) at birth or a placebo to newborns using a 2×2 factorial design.

The beneficial effect of vitamin A on child mortality has been established, [5] but the long-term benefits of early vitamin A supplementation are unclear. The GCC funded follow-up study assesses the effects of maternal and newborn vitamin A supplementation on cognitive development of children at 8 years of age.

Funders

• Grand Challenges Canada

Key Partners

• The JiVitA project and investigators
• Johns Hopkins Bloomberg School of Public Health
• Northwestern Bangladesh

Key Drivers

• Enrollment of the estimated sample size of children in the study was completed. Cognitive tests were successfully administered. Results will be discussed at the Grand Challenges meeting in Seattle.
• The successful collaboration between icddr,b, the JiVitA field site and Johns Hopkins School of Public Health made the implementation highly successful.

Challenges

Sociopolitical climate: Political unrest, strikes and roadblocks have at times hindered the ability of the study team to reach participants and carry out work; however enrollment in the follow-up study was successfully completed.

Newborn vitamin A supplementation as a strategy is currently being considered by the WHO for recommendation in low income countries, or settings where vitamin A deficiency is common.

The study team followed up 1600 children and their mothers from across four vitamin A supplementation groups in the present study. The four groups included the maternal and newborn vitamin A supplementation or placebo provided using a 2×2 factorial design. Both individual and combined effects of maternal and newborn vitamin A supplementation is being evaluated.

Through a home visit, the team assessed child morbidity, behaviour and home environment, including care-giving behaviours. A detailed history of schooling including years attended was obtained. Child anthropometry was assessed and the HOME inventory administered. Child cognition assessments were conducted at a central clinic, via tests of intelligence, motor control including fine motor skills, behavior and school achievement. Maternal IQ was also assessed.

The study team will also use extant data from the original interventions including household socioeconomic status, supplement compliance, complications and morbidity at birth, and breastfeeding patterns in the first 6 months of life.

Newborn vitamin A dosing improved infant survival through the first 6 months of life, with a 15% reduction in all-cause mortality. In line with two previous trials in South Asia, [8, 9] these data revealed an efficacy period of 4 months for Vitamin A dosing in reducing mortality, where infant survival in the vitamin A–supplemented group began to improve beyond the first week of life until week 16 of life. The estimated reduction in mortality risk in the first and next 5 months of life were 11% and 23%, respectively.

Use of weekly vitamin A or beta carotene in pregnant women did not reduce all-cause maternal, fetal, or infant mortality compared with placebo. Vitamin A supplementation, compared with either placebo or beta carotene supplementation, did however reduce maternal gestational night blindness.

The anticipated impact of the follow-up study recently completed is the quantification of antenatal and newborn vitamin A supplementation effects on child cognitive, motor and school function and thereby on human capital among children aged 8 years.

1. Alam, M. J. et al. (2012) Meeting Micronutrient Requirements for Health and Development: An Update. Bangladesh J Child Health 2012; VOL 36 (1): 36-45.
2. Global prevalence of vitamin A deficiency in populations at risk 1995–2005. WHO Global Database on Vitamin A Deficiency. Geneva: World Health Organization; 2009
3. Rotondi, M. A. et al. (2010) Vitamin A supplementation and neonatal mortality in the developing world: a meta-regression of cluster-randomized trials. Bulletin of the World Health Organization.
4. Effects of Vitamin A or Beta Carotene SupplementationonPregnancy-RelatedMortality and Infant Mortality in Rural Bangladesh JAMA, May 18, 2011—Vol 305, No. 19
5. Klemm et al (2008) Newborn vitamin A supplementation reduced infant mortality in rural Bangladesh. Pediatrics, 122: 242-250.
6. Humphrey JH et al. (1998) Neonatal vitamin A supplementation: Effect on development and growth at 3 y of age. Am J Clin Nutr. 1998;68:109-117.
7. Fawzi WW, et al. Vitamin A supplementation and child mortality. A meta-analysis.
8. Humphrey JH et al. (1996) Impact of neonatal vitamin A supplementation on infant morbidity and mortality. J Pediatr. 1996;128(4):489–496
9. Rahmathullah L et al. (2003) Impact of supplementing newborn infants with vitamin A on early infant mortality: community based randomised trial in Southern India. BMJ. 2003;327(7409):254–259