A 3-year-old girl from rural Bihar presents with night blindness and Bitot's spots on the conjunctiva. Corneal clarity is preserved. What is the drug of choice for treatment of her vitamin A deficiency?

## Vitamin A Deficiency Management — Stage-Based Approach **Key Point:** The WHO/ICMR recommended regimen for vitamin A deficiency in children (without corneal involvement) is **vitamin A palmitate 200,000 IU orally on Day 1, Day 2, and Day 15** (or 200,000 IU once daily for 2 consecutive days, then repeat after 2 weeks). ### Classification of Xerophthalmia Stages | Stage | Clinical Finding | Treatment | |-------|------------------|----------| | XN | Night blindness only | Vitamin A 200,000 IU × 2 days (oral) | | X1B | Bitot's spots (conjunctival xerosis) | Vitamin A 200,000 IU × 2 days (oral) | | X2 | Corneal xerosis (hazy, dull cornea) | Vitamin A 200,000 IU × 2 days (oral) + IM if severe | | X3A | Corneal ulceration/scarring < 1/3 | Vitamin A 200,000 IU IM immediately, then oral | | X3B | Corneal scarring > 1/3 (keratomalacia) | Vitamin A 200,000 IU IM stat, repeat Day 2 & 15 | | XS | Corneal scar | Supportive care; vitamin A for systemic deficiency | **High-Yield:** In this case, the child has **XN (night blindness) + X1B (Bitot's spots)** — early, non-corneal xerophthalmia. Oral vitamin A palmitate 200,000 IU for 2 consecutive days is the standard first-line regimen. ### Why Oral Route Here? - Cornea is **clear** (no corneal involvement). - Oral absorption is adequate in non-severe cases. - IM route reserved for corneal disease (X2 onwards) or inability to tolerate oral intake. **Clinical Pearl:** Bitot's spots are pathognomonic for vitamin A deficiency and appear as foamy, triangular patches on the temporal conjunctiva. They are **not true xerosis** but rather keratinization of conjunctival epithelium and are reversible with treatment. **Mnemonic:** **COWS** — Corneal involvement → IM; Otherwise → oral; Without corneal signs → Standard oral dose (200,000 IU × 2 days). ### Dosing Schedule 1. **Day 1:** 200,000 IU orally 2. **Day 2:** 200,000 IU orally 3. **Day 15:** 200,000 IU orally (to replenish liver stores) This regimen corrects clinical deficiency and rebuilds hepatic reserves in ~90% of cases.