What is the recommended vitamin A dosing regimen for a child with measles, including age‑specific doses and any additional considerations?

Vitamin A Supplementation in Measles

All children with clinical measles must receive vitamin A supplementation: 200,000 IU orally for children ≥12 months and adults, or 100,000 IU for infants <12 months, given on day 1. 1, 2

Standard Dosing Protocol

Age-Specific First Dose

• Children ≥12 months and adults: 200,000 IU oral vitamin A on day 1 1, 2
• Infants <12 months: 100,000 IU oral vitamin A on day 1 1, 2
• Do not administer if the patient received vitamin A supplementation within the preceding month 2

Second Dose for Complicated Measles

• Administer an identical second dose on day 2 for any of the following complications: 1, 2, 3

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

• This two-dose regimen reduces overall mortality by 64% (RR 0.36) and pneumonia-specific mortality by 67% (RR 0.33) 2, 3

• The mortality benefit is even greater in children <2 years, with an 82% reduction (RR 0.18) 2, 3, 4

Extended Protocol for Vitamin A Deficiency

Third Dose Indications

• Administer a third dose of 200,000 IU (or 100,000 IU for infants) 1-4 weeks after the initial doses if any eye symptoms of vitamin A deficiency are present: 1, 2
  • Xerosis (conjunctival or corneal dryness)
  • Bitot's spots (foamy conjunctival patches)
  • Keratomalacia (corneal softening)
  • Corneal ulceration

Evidence Quality and Rationale

The two-dose vitamin A regimen is supported by multiple randomized controlled trials and systematic reviews demonstrating substantial mortality reduction, particularly in hospitalized children in areas with high case fatality. 3, 4, 5 A landmark South African trial showed that children receiving 400,000 IU total (given as two 200,000 IU doses) had half the risk of death or major complications compared to placebo (RR 0.51), with faster recovery from pneumonia (6.3 vs 12.4 days) and diarrhea (5.6 vs 8.5 days). 5

Critical distinction: Single-dose vitamin A (200,000 IU once) has not been shown to reduce mortality (RR 0.77-1.25) and should not be used. 3, 4 The two-dose regimen is essential for benefit.

Common Pitfalls to Avoid

• Do not confuse measles with rubella (German measles): Vitamin A is indicated only for measles, not rubella, as these are distinct viral illnesses with different complication profiles. 6
• Do not use only a single dose: The evidence for mortality reduction requires two doses on consecutive days for complicated cases. 3, 4
• Do not forget the third dose: If eye symptoms of vitamin A deficiency appear, the extended three-dose protocol is mandatory to prevent permanent ocular damage. 1, 2
• Do not skip vitamin A in well-nourished populations: Even in areas where clinical vitamin A deficiency is rare, children with measles have markedly depressed serum retinol levels (92% with hyporetinemia in one study), and supplementation remains beneficial. 5

Ongoing Supplementation in High-Risk Areas

• In populations at risk for vitamin A deficiency, continue routine vitamin A supplementation every 3 months after completing the acute measles treatment protocol. 1, 2