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Another Long Vitamin K Treatise

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Other excellent resources about avoiding toxins during pregnancy

These are easy to read and understand and are beautifully presented.

Vitamin K prophylaxis is primarily used to prevent late hemorrhagic disease of the newborn (LHDN). Late onset LHDN is a syndrome of severe bleeding in infants, between one and six months of age, commonly causing Intracranial Hemorrhage with a 50% mortality rate.

The incidence is 1:1200 in the UK. It can be of idiopathic or secondary origin This occurs between 2 weeks and 6 months of age. It is due to impaired absorption of vitamin K in the newborn's gut. This can be due to immature liver function, biliary atresia or alpha antitripsin abnormalities. Often the infant has mild hepatitis with no outward symptoms and recovers spontaneously.

Recent research points to temporary inability of the liver to produce the bile salts necessary to absorb the fat soluble vitamin K.

The early and classic versions of this are far less common with the reduction in traumatic deliveries and with proper care of women on anticonvulsant and anticoagulant RX.

In Holland, where LHDN is almost non-existent, the midwives provide 1 mg vit K po at birth then the mothers give the baby 25 ug weekly po until 6 months. They have a special oral vitamin K preparation.

I have experience of two cases of LHDN in Ontario in the last few years

Case 1: LHDN, Intracranial Haemorrhage, Winter 1992
Baby boy K, born at home, spontaneous labour and birth at term. No molding or caput noted. APGAR scores 9 at 1 and 5 minutes. Parents declined vitamin K prophylaxis. Exclusively breastfed, thrived. At the age of 5 weeks the mother accidentally cut the infant's finger when clipping his nails. She paged the midwife to notify her that it took a long time to stop bleeding. The following day she paged her midwife and stated that the baby was pale, had a high pitched cry, wasn't feeding and was limp and floppy .

The midwife advised the mother to take the baby to the hospital. On admission he had prolonged clotting times which normalised after parenteral vitamin K administration. He remained in the hospital for several weeks. He has residual motor and cognitive brain damage, the extent of which will not be known until he is older.

Case 2: Late HDN? warning bleed, Spring 1994
Baby girl S. was born at home in June, 1994 at 41 weeks gestation following an uncomplicated pregnancy and labour. Her APGAR scores were 9 at one minute and 10 at 5 minutes, birthweight 7 lb.. Molding 2+ of parietal and frontal bones was noted on the newborn examination. At approximately one hour following the birth 0.5 mg of vitamin K was given orally. She received a further 0.5 mg of vitamin K orally on day 10. She was exclusively breastfed.

On day 12 her mother reported blood and mucous in her stool. The midwife assessed Baby S at home and reported as follows: Nursing vigorously Q 1-3 hours, alert, Resp. 41, apical rate 136, temp 36.1C, skin-clear, dry and pink, eyes-clear, cord stump healed, urine ++, stools-yellow curds with about 1 tsp. of mucousy red blood, weight 7 lb 6 oz.

In view of the increased risk of further bleeding and after discussion with the parents, regarding the risks of Late Haemorrhagic Disease of the Newborn (LHDN) vitamin K 1.0 mg was given intramuscularly. Consultation with a neonatologist resulted in no further treatment or investigations. Baby S has thrived since then.

Risks of Oral Vitamin K Prophylaxis

Research has demonstrated that the use of a single, oral dose of vitamin K is not protective for the more severe mortality and morbidity of LHDN. (Greer et al., 1988; Greer et al., 1995; McNinch and Tripp, 1991; Motohara et al, 1987; Shinzawa et al., 1989; Von Kries et al., 1987a) In a recent two year prospective study of 27 infants who were diagnosed with VKDB, six had been given oral vitamin K. (McNinch & Tripp, 1991) Multiple oral dose routines have problems with format of the preparation and compliance with the routine.

In a United Kingdom National cohort study of all children born during one week in 1970, vitamin K administration at birth was found to have a significant association with childhood cancer. (Golding et al., 1990) Golding et al. published a further case control study in 1992, which demonstrated parenteral vitamin K administration and smoking as independently significant factors in the subsequent development of childhood cancer.

In examining this study I found a number of factors which may have confounded the results or limit it's generalisability. Primarily, the numbers of children studied was small, only 33 children with cancer were used, this reduced the power of the study. Records of vitamin K administration, both dosage and route were of poor quality and a large number of assumptions were used to assign treatment to index cases and controls. Intravenous (IV) and intramuscular (IM) administration of vitamin K were combined. Significant differences in vitamin K levels in neonates following IV and IM vitamin K have been demonstrated in a study by Loughnan and McDougall (1995). Controls were matched to cases by age, parity and social class. A more rigorous matching to include maternal smoking, type of delivery and other potential confounding factors would have improved the strength of the study.

Three other studies have been completed in the USA, Denmark and Sweden. The American trial was a prospective case control study, while both the Danish and Swedish were retrospective case control studies. While each of these studies found the same difficulty with quality of record keeping re vitamin K administration, the degree of missing information was smaller. The Danish and Swedish studies relied on retrospective data and compared groups from different time periods. Environmental and social differences over periods of 30 years may not have been fully excluded from the results as confounding factors. None of these studies has found any causal link with childhood cancer and IM vitamin K administration.(Klebanoff, et al., 1993; Ekelund et al., 1993; Olson et al., 1995)

What I tell all clients is that like the PKU test, the vast majority of babies will not have this problem, I outline the potential risks of LHDN then let them make the choice. If they choose oral or decline any prophylaxis, I review with them the warning signs and document that informed choice was given.

This Web page is referenced from another page containing related information about Administration of Vitamin K to Newborns


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