A 5-year-old boy with protein-energy malnutrition and measles presents with corneal haziness, corneal ulceration, and risk of perforation. What is the drug of choice for immediate management of his vitamin A deficiency?

Explanation

## Vitamin A Deficiency with Corneal Disease — WHO-Recommended Oral Therapy **Key Point:** According to **WHO guidelines**, the drug of choice for vitamin A deficiency — including severe corneal disease — is **vitamin A palmitate 200,000 IU orally**, given immediately (Day 0), then on **Day 2** and **Day 15**. This applies to children ≥12 months of age. ### Why Oral Route is Preferred (Even in Corneal Disease)? 1. **WHO recommendation:** The WHO "Guideline: Vitamin A Supplementation in Infants and Children 6–59 Months of Age" and the WHO/UNICEF/IVACG Task Force guidelines explicitly recommend the **oral route** as first-line for all stages of xerophthalmia, including corneal ulceration (X2, X3A, X3B). 2. **Efficacy:** High-dose oral vitamin A palmitate achieves adequate serum retinol levels rapidly; GI absorption of oil-based preparations is sufficient even in mild malabsorption. 3. **Safety profile:** IM vitamin A preparations (water-miscible) are associated with **pain, sterile abscesses**, and inconsistent bioavailability; they are NOT recommended by WHO as first-line. 4. **IM only as fallback:** Intramuscular administration is reserved for patients with **severe vomiting, malabsorption syndromes, or inability to swallow** — not as routine first-line therapy. **High-Yield:** The **oral route** is the WHO standard of care for xerophthalmia at all stages. The IM route is a **last resort** when oral administration is truly impossible. ### WHO Dosing Schedule for Vitamin A Deficiency (Children ≥12 months) | Day | Dose | Route | |-----|------|-------| | Day 0 (immediately) | 200,000 IU | **Oral** | | Day 2 | 200,000 IU | **Oral** | | Day 15 | 200,000 IU | **Oral** | *(For children 6–11 months: 100,000 IU per dose; for infants <6 months: 50,000 IU per dose)* ### Xerophthalmia Staging (WHO) | Stage | Finding | Treatment | |-------|---------|-----------| | XN | Night blindness | Oral 200,000 IU × 3 doses | | X1A | Conjunctival xerosis | Oral 200,000 IU × 3 doses | | X1B | Bitot's spots | Oral 200,000 IU × 3 doses | | X2 | Corneal xerosis | Oral 200,000 IU × 3 doses | | X3A | Corneal ulceration <1/3 | Oral 200,000 IU × 3 doses | | X3B | Keratomalacia | Oral 200,000 IU × 3 doses | **Clinical Pearl:** Measles is a **major precipitant** of severe xerophthalmia in malnourished children. WHO recommends **immediate vitamin A supplementation** in all measles cases in endemic regions, as measles increases vitamin A catabolism and suppresses immunity. The oral route remains first-line even in this context. **Reference:** WHO. *Guideline: Vitamin A Supplementation in Infants and Children 6–59 Months of Age.* Geneva: WHO, 2011. Also: Park's Textbook of Preventive and Social Medicine, 26th ed.; Khurana's Comprehensive Ophthalmology. **Mnemonic:** **200-2-15 ORAL** — 200,000 IU orally on Day 0, Day 2, Day 15 for all xerophthalmia stages in children ≥12 months.