What are the vitamin A supplementation guidelines for measles in children (≥12 months: 200,000 IU on diagnosis day and repeat next day; 6–12 months: 100,000 IU on each of two days) and for severely malnourished or immunocompromised patients?

Vitamin A Supplementation for Measles

Standard Dosing Protocol

All children with clinical measles must receive vitamin A supplementation on day 1, with a second identical dose on day 2 for complicated cases. 1

Age-Based Dosing

• Children ≥12 months (including adults): 200,000 IU orally on day 1 1, 2
• Children 6–12 months: 100,000 IU orally on day 1 1, 3
• Infants <6 months: 100,000 IU orally on day 1 3

Two-Dose Regimen for Complicated Measles

Administer an identical second dose on day 2 when any of the following complications are present: 1

• Pneumonia or acute lower respiratory infection 1
• Otitis media 1
• Croup 1
• Diarrhea with moderate or severe dehydration 1
• Neurological problems 1

The two-dose regimen demonstrates a 64% reduction in overall mortality (RR 0.36) and a 67% reduction in pneumonia-specific mortality (RR 0.33), with an 82% mortality reduction in children <2 years (RR 0.18). 1, 4 This evidence comes from meta-analysis showing that two doses of 200,000 IU are significantly more effective than single-dose regimens, which showed no mortality benefit (RR 0.77). 4

Special Populations

Severely Malnourished Children

• Marasmic children have several-fold higher mortality regardless of vitamin A supplementation, but should still receive the standard two-dose protocol. 5
• Monitor nutritional status and enroll in supplemental feeding programs as indicated. 1, 2

Immunocompromised Patients

• Administer the standard two-dose vitamin A protocol (200,000 IU on days 1 and 2 for those ≥12 months; 100,000 IU for those <12 months). 2
• These patients should have received immune globulin 0.5 mL/kg (maximum 15 mL) within 6 days of exposure for post-exposure prophylaxis. 2

Vitamin A Deficiency with Eye Symptoms

When eye signs are present (xerosis, Bitot's spots, keratomalacia, or corneal ulceration), use an extended three-dose protocol: 1, 2

• Day 1: 200,000 IU (or 100,000 IU if <12 months) 1
• Day 2: 200,000 IU (or 100,000 IU if <12 months) 1
• 1–4 weeks later: 200,000 IU (or 100,000 IU if <12 months) 1, 2

Evidence Quality and Rationale

The recommendation for two-dose vitamin A supplementation is based on high-quality evidence from randomized controlled trials conducted in high case-fatality settings. 6, 4 Water-based formulations showed an 81% mortality reduction (RR 0.19) compared to 48% for oil-based preparations (RR 0.52), though both are effective. 4 The benefit is most pronounced in children under 2 years of age and in hospitalized children in areas with high measles case fatality. 6, 4

Critical Clinical Pitfalls

• Do not wait for laboratory confirmation before administering vitamin A—treatment should begin based on clinical diagnosis. 3
• Do not withhold vitamin A due to toxicity concerns—the standard protocol is safe, as acute toxicity requires >300,000 IU in adults or >60,000 IU in children within hours/days. 2
• Do not give vitamin A if the patient received supplementation in the preceding month, then proceed with the second dose on day 2 only if complications develop. 1
• Single-dose regimens are inadequate—evidence shows no mortality benefit from 200,000 IU given only once (RR 1.25). 1, 4

Additional Supportive Care

Beyond vitamin A, provide: 1

• Standard antibiotic therapy for secondary bacterial pneumonia 1
• Appropriate antibiotics for otitis media 1
• Oral rehydration therapy for diarrhea 1
• Antipyretics (acetaminophen or ibuprofen, not aspirin in children <16 years) 1