Vitamin A Supplementation

Survey of vitamin a supplementation for extremely-low-birth-weight infants: is clinical practice consistent with the evidence? Ambalavanan N, Kennedy K, Tyson J, and Carlo W. J Pediatr 2004;145:304-307.

Objective To survey the attitudes and practices among level III neonatal intensive care units in the United States regarding vitamin A supplementation for extremely-low-birth-weight (ELBW; birth weight

1000 g) infants.

Study design A pretested questionnaire regarding vitamin A supplementation was distributed to all (n=102) neonatal-perinatal training program directors (TPD) and 105 randomly selected directors of level III neonatal intensive care units (nontraining program directors, NTPD).

Results Ninety-nine percent of TPD and 94% of NTPD responded. In a minority of programs (20% TPD, 13% NTPD), >90% of eligible extremely-low-birth-weight neonates are supplemented with vitamin A, whereas in most programs (69% TPD, 82% NTPD), routine supplementation is not practiced. Most centers (91% TPD, 81% NTPD) supplementing vitamin A use a dose of 5000 IU IM 3 times per week for 4 weeks. The most common reason that TPD give for not supplementing vitamin A is the perceived small benefit, whereas the most common reason for NTPD is that they consider the intervention unproven.

Conclusions These findings indicate inconsistency in practicing evidence-based medicine in neonatal practice, where therapies are often administered on the basis of weaker evidence of safety and benefit than supports vitamin A supplementation. Educational interventions may be required to endorse the benefits and safety of vitamin A supplementation.

Commentary: You may recall that two of the authors of this survey were the lead investigators of the 1999 New England Journal of Medicine paper that reported the results of the Neonatal Network vitamin A trial, so that five year later, this is vitamin A redux. Let us revisit the published results on the primary outcomes in this trial. Yes, the incidence of “death or BPD” in infants at 36 weeks postconceptional age were 55% in the vitamin A supplemented group and 62% in the placebo group, for a “number needed to treat” of 14-15 to prevent one case of “death or BPD”. But on closer inspection, this may not be so impressive. Death was no different at 36 weeks (15% vs. 14%) or at discharge (17% vs. 16%). The percentage of infants on ventilators at 36 weeks was 7% in the vitamin A group and 6% in the placebo group. At 36 weeks, the percentages of infants on supplemental oxygen and room air were 40%/45% in the vitamin A group vs. 48%/38% in the placebo group. There were no significant differences in any other outcomes (including length of stay). This survey found that a large majority of neonatologists do not provide intramuscular vitamin A supplementation to preterm infants (a course of 12 injections over 4 weeks), primarily because they consider the benefit to be small or unproven. What is your position on vitamin A? I do think that the authors have a point – we as a group are as likely to employ a therapy that “might” help without the appropriate evidence-based studies as we are not to utilize some therapies with proven advantages. I just do not think that vitamin A is the best example of the latter situation. – MLH

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