NY Times: Vitamin K for Newborns is a No-Brainer

One of the most difficult clinical situations I helped manage involved a newborn who had a devastating intracranial hemorrhage after the parents had refused the routine  administration of vitamin K.  At that time, I did not ask the parents what they were thinking.  I presumed that they were well-intentioned.  Nevertheless, they allowed their child to suffer permanent neurologic injury.

A recent editorial highlights this growing problem: NY Times: Vitamin K for Newborns is a No-Brainer Here’s an except:

Parents are increasingly questioning, and declining, vitamin K, which protects newborns from serious bleeding…

Accounts of healthy babies developing serious, even fatal bleeding in the days and weeks following birth can be found going back centuries

Since the early 1960s, it has been standard-of-care for newborns to receive an intramuscular injection of vitamin K shortly after delivery. Nearly six decades’ worth of data demonstrate that this intervention virtually eliminates vitamin K deficiency bleeding and carries no compelling risk of serious side effects…

Many of the reasons my patients’ parents decline vitamin K are similar to the reasons they decline vaccines: They worry about interventions they perceive as “unnatural” or unnecessary, about whether the doses and ingredients are “toxic” and whether there may be serious complications that doctors are not aware of or that are even being purposefully obscured by doctors, public health officials and pharmaceutical companies…

Parents continue to ask me whether vitamin K might cause childhood cancer, though this suggested association has been debunked….Others simply prefer to spare their newborn the pain of an injection…

Each year in the United States, if no vitamin K were administered, more than 70,000 infants would most likely be affected…

The seeds of mistrust — along with skepticism of science and intellectualism, the allure of the “natural” and the development of social-media-fueled communities founded on these values — run deep, and they’re threatening the health of our youngest and most vulnerable.

My take: Just like seat belts, the approach to this problem should be policy-based.  In my view, if an infant suffers from vitamin K-refusal bleeding, reports should be made public health departments.

Related blog post: Educated or Misinformed –Leading to Hemorrhagic Disease of the Newborn

Bleeding due to vitamin K deficiency

With cholestasis in infancy, Bill Balistreri taught me that there were four potential emergencies:

  • Bleeding due to vitamin K deficiency or coagulopathy
  • Hypoglycemia
  • Sepsis
  • Metabolic poisoning with formula (in patients with galactosemia)

Once these issues have been considered, then it is appropriate to start investigating the etiology of the cholestasis.

One of the more dramatic complications is intracranial hemorrhage (ICH). While ICH is a well-recognized complication of cholestasis in infancy, the long-term outcomes are not well-characterized. A report from Japan adds some insight (JPGN 2012; 54: 552-57).

Among a retrospective review of 83 infants with biliary atresia (BA) between 1979 to 2009, ICH occurred in 8% despite oral vitamin K prophylaxis (2 mg).  The onset of ICH was between 47-76 days after birth and was prior to surgery.  Coagulopathy was noted in all cases, which improved with vitamin K intravenously.  Two infants required craniotomy.  In 5 of 7 cases, neurologic sequelae were noted including developmental delay in three, epilepsy in one, and mild hemiparesis in two.

Additional references:

  • Blood Rev 2009; 23: 49-59.  Review of vitamin K deficiency.
  • Pediatrics 2008; 121:e857.  Vitamin K deficiency common in cholestatic breastfed babies.  Can be prevented with 1mg po each week or single IM dose of 2mg.
  • Eur J Pediatr Surg 2005; 15: 295-9.  Bleeding disorder as 1st symptom of BA.
  • Pediatr Neurosurg 2006; 42: 362-7.  ICH due to vitamin K deficiency.
  • Pediatrics 2006; 118: e1657.  dose of 0.2mg effective for median of 25days (w/o toxicity/accumulation of K1O) in infants <32weeks gestation.