Vitamin K deficiency bleeding

Not to be confused with Haemolytic disease of the newborn.

Vitamin K deficiency bleeding of the newborn

Other names: Haemorrhagic disease of the newborn
Vitamin K1
Symptoms| Bleeding
Usual onset| Birth to 2 months of age
Types| Early, Classical, Late
Causes| Vitamin K deficiency
Prevention| Vitamin K supplementation after birth

Vitamin K deficiency bleeding (VKDB) of the newborn, previously known as haemorrhagic disease of the newborn,[1] is a rare form of bleeding disorder that affects newborns and young infants due to low stores of vitamin K at birth.[2] It commonly presents with intracranial haemorrhage with the risk of brain damage or death.[3]

Newborn infants have low stores of vitamin K, and human breast milk has low concentrations of the vitamin. This combination can lead to vitamin K deficiency and later onset bleeding. Vitamin K deficiency leads to the risk of blood coagulation problems due to impaired production of clotting factors II, VII, IX, X, protein C and protein S by the liver. More rarely VKDB can be caused by maternal medicines causing vitamin K deficiency in the newborn.[2]

VKDB can largely be prevented by prophylactic supplementation of vitamin K, which is typically given shortly after birth by intramuscular injection. Most national health organisations recommend routine vitamin K supplementation after birth.[2] Widespread use of this has made this a rare disease.

## Contents

* 1 Classification
* 2 Signs and symptoms
* 3 Causes
* 4 Diagnosis
* 5 Prevention
* 5.1 Controversy
* 6 Treatment
* 7 References
* 8 External links

## Classification[edit | edit source]

VKDB is classified as early, classical or late depending on when it first starts with each having somewhat different types of bleeding and underlying cause:

Classification of vitamin K deficiency in the newborn (VKDB)[2] Syndrome | Time of onset | Common sites of bleeding | Potential causes

|
|
|

Early | First 24 hours | Scalp, skin, brain, chest, abdomen | Maternal medications
Classical | 1-7 days | Gut, umbilicus, skin, nose, circumcision | Idiopathic, breast feeding
Late | After day 8 | Brain, skin, gut | Idiopathic, breast feeding, cholestasis

## Signs and symptoms[edit | edit source]

Multiple nodular lesions on right elbow, right knee, and lateral side of chest (black arrows)

VKDB presents typically in the first month of life with bleeding which can be from various locations. Late onset VKDB presents with bleeding into the brain (intracranial haemorrhage) in more than half of cases.[2]

## Causes[edit | edit source]

Newborns are relatively vitamin K deficient for a variety of reasons: They have low vitamin K stores at birth as vitamin K passes the placenta poorly. Levels of vitamin K in human breast milk are low. Gut flora, that in adults produces vitamin K, has not yet developed.[2] Early VKDB is rare and caused by maternal medications that interact with vitamin K such as warfarin, phenytoin, or rifampicin.[2]Classical VKDB is more common and caused by the relative deficiency at birth with inadequate vitamin K intake. This is often termed idiopathic as no one cause is found[citation needed].Late VKDB presents after day 8 and up to 6 months of age, coinciding with the typical age for exclusive breast feeding due to the low levels of vitamin K in human breast milk. Many of these infants have poor vitamin K absorption due to cholestasis which compounds low intake.[2]

## Diagnosis[edit | edit source]

Bleeding in an infant without vitamin K supplementation with elevated prothrombin time (PT) that is corrected by vitamin K administration is typically sufficient to make the diagnosis. Confirmation, or investigation of minor deficiency, can be performed by testing proteins produced in the absence of vitamin K, the most established assay being for PIVKA-II.[2]

## Prevention[edit | edit source]

Late onset VKDB is nearly completely prevented by early supplementation of vitamin K which is typically given to newborns shortly after birth.[2][4][5] The most effective method of administration is by intramuscular injection shortly after birth but it can be given orally in three doses over the first month.[2] [6]

It is not possible to reliably distinguish which infants are at high risk of late VKDB and the potential consequences are high, as such most national health organisations recommend routine supplementation in the first 24 hours of life.[2]

### Controversy[edit | edit source]

Controversy arose in the early 1990s regarding routine supplementation, when two studies suggested a relationship between parenteral administration of vitamin K and childhood cancer.[7] However, both studies have been discredited on the basis of poor methodology and small sample sizes, and a review of the evidence published in 2000 by Ross and Davies found no link between the two.[8]

## Treatment[edit | edit source]

Treatment of established bleeding depends on the location but includes vitamin K1 (phylloquinone; phytomenadione; phytonadione) administration which restores the prothrombin time rapidly. Severe bleeding may require blood products such as fresh frozen plasma (FFP), a prothrombin complex concentrate (PCC).[2]

## References[edit | edit source]

1. ↑ Sutor, Anton; von Kries, Rüdiger; Cornelissen, Marlies; McNinch, Andrew; Andrew, Maureen (9 December 2017). "Vitamin K Deficiency Bleeding (VKDB) in Infancy". Thrombosis and Haemostasis. 81 (3): 456–461. doi:10.1055/s-0037-1614494.
2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 Shearer, Martin J. (March 2009). "Vitamin K deficiency bleeding (VKDB) in early infancy". Blood Reviews. 23 (2): 49–59. doi:10.1016/j.blre.2008.06.001. PMID 18804903.
3. ↑ Volpe, Joseph J (2017-10-06). Volpe's neurology of the newborn (Sixth ed.). ISBN 978-0-323-42876-7. Archived from the original on 2020-10-31. Retrieved 9 March 2020.
4. ↑ American Academy of Pediatrics Committee on Fetus Newborn (July 2003). "Controversies concerning vitamin K and the newborn. American Academy of Pediatrics Committee on Fetus and Newborn" (PDF). Pediatrics. 112 (1 Pt 1): 191–2. doi:10.1542/peds.112.1.191. PMID 12837888. Archived (PDF) from the original on 2014-10-31. Retrieved 2021-05-07.
5. ↑ Logan S, Gilbert R (1998). "Vitamin K For Newborn Babies" (PDF). Department of Health. Archived from the original (PDF) on 7 January 2013. Retrieved 12 Oct 2014.
6. ↑ "Postnatal care up to 8 weeks after birth". www.nice.org.uk. NICE. Archived from the original on 24 January 2020. Retrieved 9 March 2020.
7. ↑ Parker L, Cole M, Craft AW, Hey EN (January 1998). "Neonatal vitamin K administration and childhood cancer in the north of England: retrospective case-control study". BMJ. 316 (7126): 189–93. doi:10.1136/bmj.316.7126.189. PMC 2665412. PMID 9468683.
8. ↑ McMillan DD, et al. (Canadian Paediatric Society, Fetus and Newborn Committee) (1997). "Routine administration of vitamin K to newborns". Paediatrics & Child Health. 2 (6): 429–431. doi:10.1093/pch/2.6.429. PMC 7745636.

## External links[edit | edit source]

Classification|

* ICD-11: KA8F.0
* ICD-10: P53
* ICD-9-CM: 776.0
* MeSH: D006475
* DiseasesDB: 29544
* SNOMED CT: 12546009

|

External resources|

* MedlinePlus: 007320
* eMedicine: article/974489
* Patient UK: Vitamin K deficiency bleeding

* v
* t
* e

Conditions originating in the perinatal period / fetal disease

Maternal factors
complicating pregnancy,
labour or delivery|

| placenta|

* Placenta praevia
* Placental insufficiency
* Twin-to-twin transfusion syndrome

|

chorion/amnion|

* Chorioamnionitis

umbilical cord|

* Umbilical cord prolapse
* Nuchal cord
* Single umbilical artery

presentation|

* Breech birth
* Asynclitism
* Shoulder presentation

Growth|

* Small for gestational age / Large for gestational age
* Preterm birth / Postterm pregnancy
* Intrauterine growth restriction

Birth trauma|

* scalp
* Cephalohematoma
* Chignon
* Caput succedaneum
* Subgaleal hemorrhage
* Brachial plexus injury
* Erb's palsy
* Klumpke paralysis

Affected systems|

| Respiratory|

* Intrauterine hypoxia
* Infant respiratory distress syndrome
* Transient tachypnea of the newborn
* Meconium aspiration syndrome
* Pleural disease
* Pneumothorax
* Pneumomediastinum
* Wilson–Mikity syndrome
* Bronchopulmonary dysplasia

|

Cardiovascular|

* Pneumopericardium
* Persistent fetal circulation

Bleeding and
hematologic disease|

* Vitamin K deficiency bleeding

* HDN
* ABO
* Anti-Kell
* Rh c
* Rh D
* Rh E
* Hydrops fetalis
* Hyperbilirubinemia
* Kernicterus
* Neonatal jaundice

* Velamentous cord insertion
* Intraventricular hemorrhage
* Germinal matrix hemorrhage
* Anemia of prematurity

Gastrointestinal|

* Ileus
* Necrotizing enterocolitis
* Meconium peritonitis

Integument and
thermoregulation|

* Erythema toxicum
* Sclerema neonatorum

Nervous system|

* Perinatal asphyxia
* Periventricular leukomalacia

Musculoskeletal|

* Gray baby syndrome
* muscle tone
* Congenital hypertonia
* Congenital hypotonia

Infections|

* Vertically transmitted infection
* Neonatal infection
* rubella
* herpes simplex
* mycoplasma hominis
* ureaplasma urealyticum
* Omphalitis
* Neonatal sepsis
* Group B streptococcal infection
* Neonatal conjunctivitis

Other|

* Miscarriage
* Perinatal mortality
* Stillbirth
* Infant mortality
* Neonatal withdrawal

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