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VITAMIN K AND HAEMORRHAGIC DISEASE OF THE NEWBORN

The facts about vitamin k and blood clotting:

 Vitamin K is a fat soluble vitamin that we obtain from our diet and from the
bacteria in the gut, we make it.

Vitamin K is necessary for the blood to clot normally

 Newborn babies have prolonged clotting times this is because the blood needs to
flow through the network of small vessels in the placenta without clotting.

 The blood clotting times become prolonged after the birth until around day five
and then gradually return to normal by the seventh day
 Vitamin K is given to protect babies against haemorrhagic disease of the
newborn
 Mature breastmilk contains little vitamin K, whereas colostrums is rich in it.
 Baby formula milks all have vitamin K added to them

Haemorrhagic disease of the newborn

Excessive bleeding is more likely to occur early in the first week of life, however
dangerous haemorrhage may occur late at any time until the child is fully weaned. Some
babies are clearly at higher risk than others but half of the cases occur without any risk
factors having been identified.

Risk factors:

 Babies born before 36wks

 If a baby has an infection
 If baby is born small and under weight
 If the baby needs help to establish breathing at birth
 If the baby has bruises
 If the baby is being circumcised
 Unwell babies
 Babies who are unable to feed or are not absorbing their feeds
 Caesarean section or forceps or ventouse
 Breech births
 Mum is epileptic or has TB
  Mums who are drug users or mal nourished
 Mum or baby have liver disease

Facts

 The disease can present either early or late

 In the first week the baby may ooze from the cord stump, have stomach bleeding
which is often not severe or more rarely bleeding into the brain
 The early disease is more common 1-2% of babies who have NOT had the
vitamin K.
 Late onset of the disease is more severe. The babies have a large sudden bleed
often into the brain. It occurs in exclusively breastfeeding babies or bottle
feeding babies that are not absorbing their feeds properly. In most cases the
mother or baby are usually discovered to have a liver disease. It is rare and
occurs 5-10 babies out of every 100,000 babies.
 The treatment is vitamin K by injection and a transfusion of fresh frozen plasma
which is a blood product.

Choices:

1. NO VITAMIN K——— if the baby is NOT in a high risk group the chances of
baby suffering a significant haemorrhage is 1:10 000. Of these children 1:4 to 1:8
will suffer brain damage and 1:10 will die.
2. ORAL VITAMIN K——–if the baby receives one dose the risk of the baby
suffering a haemorrhage is 1:20 000. If the baby receives a full course the chance
of significant haemorrhage is unknown although some cases have been reported.
3. INJECTION OF VITAMIN K——-the baby is protected against the disease
unless there is a problem with the liver.

Considerations
 A study published in 1992 suggested that the vitamin K injection was associated
with an increased risk of childhood cancer. Oral vitamin K was used in many
centres as a result.
 Further studies published in 1993 and 1996 were unable to find the same
association. It was therefore felt that the original claim was unsubstantiated. The
use of vitamin K injection as routine started to become widespread again.
 Out of four studies published in 1998, only one found no link between the
injection of vitamin K and cancer, the remaining 3 were unable to exclude a
possible increased risk of contracting leukaemia in 1 to 6 year olds. The
recommendations by the authors of these studies is that `whilst a small risk
cannot be excluded, it seems prudent to recommend a policy of giving injections
of vitamin K only to those babies at particularly high risk and orally to others.`
 Although there is a product licensed for use orally, it is not widely used it is very
expensive and the dose is very high.
 It is usual to give the preparation for injection orally, and in repeated doses,
there are any number of protocols for giving it, each hospital deciding what they
 think is best. Often babies are not actually given all the doses that are
prescribed. There is some evidence that supplementation of oral vitamin k
should continue until the baby is weaned.
 Vitamin k given by injection involves giving one dose. The baby receives the
injection, usually into the leg muscle soon after birth at the same time as the
baby being weighed and generally checked over.
 Ensuring the baby receives the maximum amount of colostrums may be
protective against the early disease.

Risk assessment for vitamin K

1. What is the risk of my child suffering significant  haemorrhage if he/she receives

no vitamin k and he/she are not in a high risk group? 1:10 000

Of these children 1:4 will be brain damaged and 1:10 will die.

 2.       What is the risk of my child suffering significant haemorrhage if he/she receives
only one dose of oral vitamin K at birth? 1:20 000

1. 3.       What is the risk of my child suffering significant bleeding if he/she received
a full course of oral vitamin K supplement? Unknown, although there have been
some reported cases.

1. 4.       What is the increased risk of childhood cancer from vitamin K? NONE

1. 5.       What is the increased risk of childhood leukaemia from vitamin K?

UNCERTAIN

BOYS LEUKAEMIA RATE PER YEAR 0-15 INCREASED FROM 38:1 000 000 TO
41: 1 000 000

GIRLS LEUKAEMIA RATE PER YEAR 0-15 INCREASED FROM 30: 1 000 000 TO
33: 1 000 000

90% OF ALL LEUKAEMIAS ARE NOW CURABLE

References
Elaine B St John, MD, Associate Professor of Pediatrics, Division of Neonatology,
University of Alabama at Birmingham School of Medicine

http://emedicine.medscape.com/article/974489-overview

von Kries R. Neonatal vitamin K prophylaxis: the Gordian knot still awaits untying. BMJ
1998; 316: 161-2

Golding J. Factors associated with childhood cancer in a national cohort study. Br J Cancer
1990; 62: 304-8.

Golding J. Childhood cancer, intramuscular vitamin K, and pethidine given during labour.
BMJ 1992; 305: 341-46.

Klebanoff MA, The risk of childhood cancer after neonatal exposure to vitamin K. N Engl J
Med 1993; 329: 905-8

Ekelund H, Administration of vitamin K to newborn infants and childhood cancer. BMJ

1993; 307: 89-91

Ansell P, Childhood leukaemia and intramuscular vitamin K: findings from a case-control

study. BMJ 1996; 313: 204-5

von Kries R, Vitamin K and childhood cancer: a population based case-control study in
Lower Saxony, Germany. BMJ 1996; 313: 199-203.

McKinney PA. Case-control study of childhood leukaemia and cancer in Scotland: findings
for neonatal intramuscular vitamin K. BMJ 1998; 173-7.

Passmore SJ. Case Controlled studies of relationship between childhood cancer and
neonatal vitamin K administration. BMJ. 1998; 316: 178-84.

Passmore SJ. Ecological studies of relation between hospital policies on neonatal vitamin K
administration and subsequent occurrence of childhood cancer. Br Med J 1998; 316: 184-9

Parker L. Neonatal vitamin K administration and childhood cancer in the north of England:
retrospective case-control study. Br Med J 1998; 316: 189-93
Cornellison M., et al. Prevention of Vitamin K deficiency bleeding: efficacy of different
multiple oral dose schedules of Vitamin K. European J of Paed 1997; 156: 126-130.

Zipursky A. Prevention of Vitamin K deficiency in a newborn. Brit J Haematology 1999; 104:

430-437.

von Kries A.. Oral mixed mycellular Vitamin K for the prevention of late Vitamin K
deficiency bleeding. Arch Dis Child Fetal Neonatal Ed. 2003; 88: F109-112.

Loughnan P, et al.  The frequency of late onset haemorrhagic disease (HD) in Australia with
different methods of prophylaxis, 1993-1997.  An update.  J Paediatr Child Health
1999;38:A8.

Puckett RM, Offringa M. Prophylactic vitamin K for vitamin K deficiency bleeding in

neonates.Department of Pediatrics, H3-150, Academic Medical Center, P.O. Box 22700,
1100 DE Amsterdam, Netherlands.