Preventing Vitamin K Deficiency Bleeding in the Newborn

Vitamin K is an important component in the clotting cascade. Without it, newborn infants are at greater risk of haemorrhagic disease, with potentially fatal consequences. This is why all newborn babies are offered prophylactic Vitamin K in the immediate period after birth as a routine therapeutic intervention (Royal College of Midwives 2012).

Haemorrhagic Disease of the Newborn

Haemorrhagic disease of the newborn (HDNB) was first identified over a century ago. It describes bleeding in the newborn that is not due to traumatic birth or haemophilia. Caused by vitamin K deficiency due to insufficient prenatal storage of vitamin K, combined with insufficient vitamin K in breast milk, HDNB presents as unexpected bleeding, often with gastrointestinal haemorrhage, ecchymosis and intracranial haemorrhage (Ng and Loewy 2018).

Recognising this, the term vitamin K deficiency bleeding (VKDB) was adopted to describe the cause of the bleeding.

All newborn babies have inadequate reserves of Vitamin K at birth. This is partly because Vitamin K1 does not cross the placenta easily, resulting in low fetal plasma concentrations, and partly because vitamin K is found in relatively low concentrations in breast milk, making breastfed babies particularly vulnerable to VKDB (Australian College of Midwives 2010).

Three Types of Vitamin K Deficiency

There are three types of vitamin K deficiency bleeding (VKDB) that have been identified, each classified according to when symptoms first appear:

1. Early-onset occurs within the first 24 hours of birth and is often associated with maternal medications that inhibit vitamin K activity, such as antiepileptic medications.
2. Classic onset occurs between days 2 to 7 and is associated with a low intake of vitamin K.
3. Late-onset presents either at 2 to 12 weeks, or up to 6 months of age and is associated with chronic malabsorption and low vitamin K intake. This occurs almost exclusively in breastfed babies.

(Ng and Loewy 2018)

Vitamin K Prophylaxis

As Ng and Loewy (2018) report, vitamin K prophylaxis has been well-researched and shown to effectively reduce vitamin K deficiency bleeding of any severity in the first week of life. Most researchers agree that a single intramuscular injection of vitamin K at birth can effectively prevent VKDB, whereas single or repeated doses of oral vitamin K are known to be less effective.

Based on this evidence, Mihatsch et al. (2016) suggest that all newborn infants should receive vitamin K prophylaxis, with healthy term babies receiving either 1 mg of vitamin K1 by intramuscular injection or three doses of 2 mg vitamin K1 orally at birth, repeated at four to six days and again at four to six weeks. Although many parents prefer the idea of oral administration, it’s known to be less effective as protocols and rates of compliance can vary widely between health authorities. Other disadvantages of oral administration include the baby spitting out the dose of vitamin K or vomiting within the first hour of administration.

Bearing all these factors in mind the Australian College of Midwives (2010) has made the following recommendations:

1. All newborn infants should receive vitamin K prophylaxis.
2. Healthy newborn infants should receive vitamin K either:
   • by intramuscular injection of 1 mg (0.1 mL) at birth, or
   • as three 2 mg (0.2 mL) oral doses given at birth, at the time of newborn screening between three to five days of age and again in the fourth week.

This final dose is not required in babies who are predominantly bottle-fed, as milk formulas naturally contain vitamin K supplementation. It’s also important that the third dose is given no later than four weeks after birth, as the effect of earlier doses is known to decrease after this time (ACM 2010).

Vitamin K Prophylaxis for Preterm Infants

For preterm babies, the situation is slightly different as they are at even greater risk of vitamin K deficiency bleeding due to hepatic immaturity and delayed gut colonisation with microflora. Yet, despite this increased vulnerability, recommendations for vitamin K prophylaxis at birth for preterm infants can vary widely in terms of dosage and routes of administration, with little in the way of good quality research-based evidence to support any one clinical practice (Ng & Loewy 2018).

Managing Parental Refusal

Mihatsch et al. (2016) note that parents who receive prenatal education about the importance of vitamin K prophylaxis are far more likely to comply with administration after birth. The nurses and midwives who administer the vitamin K also have a key role to play in educating and reassuring parents (Holley et al. 2020).

That said, according to Hamrick et al. (2015), the most common source of information for parents is the internet, with over 70% of parents saying they are influenced by online information. Common concerns frequently mentioned by parents include fears about:

• Synthetic or toxic ingredients
• Excessive dose
• Side effects.

As a result, and with increasing numbers of parents refusing intramuscular administration of vitamin K at birth, the Australian College of Midwives (2010) recommends that:

• Parents should receive written information during the antenatal period about the importance of vitamin K prophylaxis, and the options and relevance of oral or intramuscular prophylaxis.
• Health practitioners should ensure that appropriate informed consent procedures are in place and followed.
• A mechanism should be in place to ensure that the decision made antenatally about the method of prophylaxis is still valid and is clearly communicated to the staff caring for the mother during childbirth and postnatally.

Loyal et al. (2019) has explored the reasons behind parental reluctance to allow vitamin K administration and discovered the following four major themes:

1. Risk-to-benefit ratio, where parents refuse intramuscular vitamin K due to a perceived risk to their newborn from preservatives.
2. ‘Natural’ approaches, which lead to seeking oral vitamin K or increasing the mother's own prenatal dietary vitamin K intake.
3. Placement of trust and mistrust, which involves mistrust of the medical and pharmaceutical community with overlapping concerns about vaccines.
4. Reflections on prior hospital visits and poor communication with health care providers.

As Eventov-Friedman et al. (2013) note, the increasing rate of refusal of intramuscular vitamin K needs further investigation to determine how to overcome resistance, increase uptake and provide expecting parents with information about the safety and benefits of vitamin K prophylaxis.

Parents’ perception of risk, preference for alternative options, trust, and communication with health care providers are all important factors when making decisions about administering vitamin K. Yet, parents are not alone in their concerns, as clinicians are also more aware than ever of the potentially harmful effects of early pain exposure (Ng and Loewy 2018).

And so, the search continues for pain-free, safe and effective ways to administer vitamin K and prevent vitamin K deficiency bleeding.

References

• Australian College Of Midwives 2010, Vitamin K Administration to Newborn Infants to Prevent Vitamin K Deficiency Bleeding in Infancy, ACM 2010, viewed 13 August 2020, https://www.midwives.org.au/resources/vitamin-k-administration-newborn-infants-prevent-vitamin-k-deficiency-bleeding-infancy-joi
• Eventov-Friedman, S, Vinograd, O, Ben-Haim, M, Penso, S, Bar-Oz, B & Zisk-Rony, R 2013, 'Parents’ Knowledge and Perceptions Regarding Vitamin K Prophylaxis in Newborns', Journal of Pediatric Hematology/Oncology, vol. 35, no. 5, pp.409-413, viewed 13 August 2020, https://journals.lww.com/jpho-online/Abstract/2013/07000/Parents__Knowledge_and_Perceptions_Regarding.14.aspx
• Hamrick, H, Gable, E, Freeman, E, Dunn, L, Zimmerman, S, Rusin, M, Linthavong, O, Wright, M, Moss, L & Skinner A 2015, 'Reasons for Refusal of Newborn Vitamin K Prophylaxis: Implications for Management and Education', Hospital Pediatrics, vol. 6, no. 1, pp.15-21, viewed 13 August 2020, https://hosppeds.aappublications.org/content/6/1/15.short
• Holley, S, Green, K, Mills, M, Detterman, C, Rappold, M & Thayer, S 2020, 'Educating Parents on Vitamin K Prophylaxis for Newborns', Nursing for Women's Health, vol. 24, no. 4, pp.283-293, viewed 13 August 2020, https://www.sciencedirect.com/science/article/abs/pii/S1751485120300994
• Loyal, J, Weiss, T, Cheng, J, Kair, L and Colson, E, 2019, 'Refusal of Vitamin K by Parents of Newborns: A Qualitative Study', Academic Pediatrics, vol. 19, no. 7, pp.793-800, viewed 13 August 2020, https://www.sciencedirect.com/science/article/abs/pii/S1876285919301135
• Mihatsch, W, Braegger, C, Bronsky, J, Campoy, C, Domellöf, M, Fewtrell, M, Mis, N, Hojsak, I, Hulst, J, Indrio, F, Lapillonne, A, M⊘lgaard, C, Embleton, N and van Goudoever, J, 2016, 'Prevention of Vitamin K Deficiency Bleeding in Newborn Infants', Journal of Pediatric Gastroenterology & Nutrition, vol. 63, no. 1, pp.123-129, viewed 13 August 2020, https://journals.lww.com/jpgn/FullText/2016/07000/Prevention_of_Vitamin_K_Deficiency_Bleeding_in.26.aspx
• Ng, E & Loewy, A, 2018, 'Guidelines for Vitamin K Prophylaxis in Newborns', Paediatrics & Child Health, vol. 23, no. 6, pp.394-397, viewed 13 August 2020, https://academic.oup.com/pch/article/23/6/394/5075070
• Royal College Of Midwives 2012, Immediate Care of the Newborn, Royal College Of Midwives, viewed 13 August 202, https://www.rcm.org.uk/media/2280/evidence-based-guidelines-immediate-care-of-the-newborn.pdf