A 5-year-old boy with protein-energy malnutrition and corneal ulceration due to vitamin A deficiency is admitted to a district hospital in rural Uttar Pradesh. He has severe diarrhoea and suspected malabsorption. Which is the preferred route and drug for immediate vitamin A therapy?

Explanation

## Vitamin A Therapy in Malabsorption and Corneal Disease ### Clinical Context: Why IM Route Is Preferred Here **Key Point:** In the presence of **malabsorption** (diarrhoea, PEM) and **corneal involvement** (corneal ulceration = stage X3, the most severe), the **intramuscular route** is mandatory to bypass GI absorption defects and ensure rapid, reliable delivery. ### Comparison of Routes and Formulations | Route | Formulation | Dose | Indication | Limitation | |-------|-------------|------|-----------|------------| | **Oral** | Vitamin A palmitate / acetate | 200,000 IU days 1, 2, 15 | Normal GI absorption | Fails in diarrhoea, malabsorption | | **IM (preferred in this case)** | Vitamin A palmitate / acetate | 200,000 IU days 1, 2, 15 | Malabsorption, corneal disease | None — gold standard for severe cases | | IV | Not recommended | — | — | Risk of toxicity, no advantage over IM | **High-Yield:** Corneal ulceration (stage X3) is a **medical emergency** requiring immediate, high-dose vitamin A. Malabsorption (diarrhoea) is an absolute indication to switch from oral to **IM administration**. ### Why IM Is Mandatory in This Case 1. **Bypasses GI pathology:** IM injection avoids the damaged intestinal mucosa causing diarrhoea and malabsorption. 2. **Ensures bioavailability:** Direct hepatic uptake guarantees repletion, unlike oral therapy which may be lost in stool. 3. **Prevents blindness:** Corneal ulceration can progress to perforation and irreversible blindness within days; IM dosing provides fastest repletion. 4. **WHO-endorsed:** All international guidelines recommend IM for corneal xerophthalmia + malabsorption. **Clinical Pearl:** A child with corneal ulceration and diarrhoea is at imminent risk of permanent blindness. IM vitamin A is not optional — it is the standard of care and may be the difference between sight and blindness. **Warning:** Do NOT use oral vitamin A in a child with active diarrhoea and corneal disease. The drug will be poorly absorbed and the cornea may perforate while awaiting therapeutic levels.