1. Department of International Health Newborn Vitamin A Supplementation and Early Infant Mortality: Current Evidence James Tielsch, Ph.D. Bangkok, March 2010

2. Newborn Vitamin A Supplementation Background Vitamin A supplementation well accepted intervention for children 6 – 72 months of age. Evidence for children <6 m, suggested no impact on child mortality. Newborn period (first few days) may be different: Almost all infants born with very low reserves. Breastfeeding women often vitamin A deficient. Trial in very preterm infants in US showed reduced rate of BPD.

3. Presenter’s Name Date Randomized Trials in South and SE Asia StudyCountryDesign Study Size (Live Births) Age at Dosing Humphrey et al. (1996) Indonesia Hospital-based individually randomized trial Vit. A: 1034 Control:1033 Mean = 16.4hrs 88.2% within 24 hrs Rahmathullah et al. (2003) India Community-based individually randomized trial Vit. A: 5,786 Control: 5,833 Median = 26hrs 80% within 48 hrs Klemm et al. (2009) Bangladesh Community-based cluster randomized trial Vit. A:7.953 Control: 7,984 Median = 7hrs 84% within 48 hrs Bhutta et al. (unfinished) Pakistan Community-base cluster randomized trial Vit. A: 180 clusters Cont.: 180 clusters Not completed ? (unfinished) India???

4. Presenter’s Name Date Randomized Trials in South and SE Asia StudyCountryResults Humphrey et al. (1996)Indonesia RR (IMR) =0.36 (0.16, 0.87) Rahmathullah et al. (2003) India RR (6m IMR) = 0.78 (0.63, 0.96) Klemm et al. (2009)Bangladesh RR (6m IMR) =0.85 (0.73, 1.00) POOLED India & Bangladesh RR = 0.83 (0.72-0.94)

5. Presenter’s Name Date Pooled Results by Maternal Characteristics

6. Presenter’s Name Date Pooled Results by Infant Characteristics

7. Presenter’s Name Date Randomized Trials in Africa Two trials in Africa have shown no impact of newborn vitamin A supplementation on early infant mortality. Zimbabwe (HIV neg infants) No maternal vitamin A deficiency. Very low mortality rates. Guinea Bissau Little vitamin A deficiency Combined with BCG vaccination Provided care for sick infants. Other reasons ??? Zambia trial just getting started. ? SHOULD DATA BE COMBINED WITH ASIAN TRIALS ?

8. Presenter’s Name Date Conclusions Trials from Asia provide strong evidence that supplementation with 50,000 IU vitamin A within the first few days after birth reduces early infant mortality in south & southeast Asian settings. Waiting until 2 or more weeks after birth will likely have little impact on mortality. Newborn vitamin A supplementation is unlikely to have an impact in settings with little maternal vitamin A deficiency and where early infant mortality rates are already low. Newborn vitamin A supplementation is a highly cost- effective intervention that can assist countries in meeting MDG-4.