eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Neonatology

Hemorrhagic Disease of Newborn: Differential Diagnoses & Workup

Author: Dharmendra J Nimavat, MD, FAAP, Assistant Professor of Clinical Pediatrics, Department of Pediatrics, Division of Neonatology, Southern Illinois University School of Medicine
Coauthor(s): Michael P Sherman, MD, Professor, Department of Child Health, University of Missouri-Columbia School of Medicine; Director, Fellowship Training Program in Neonatal-Perinatal Medicine, NICU, Columbia Regional Hospital; Professor Emeritus, Department of Pediatrics, University of California, Davis, School of Medicine
Contributor Information and Disclosures

Updated: Sep 14, 2009

Differential Diagnoses

Consumption Coagulopathy
Von Willebrand Disease

Other Problems to Be Considered

Maternal isoimmune thrombocytopenia
Alloimmune thrombocytopenia
Hepatobiliary disease
Uncommon coagulopathies

Workup

Laboratory Studies

  • A prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen levels, and a platelet count should be included in the initial workup for vitamin K deficiency bleeding (VKDB) in a newborn. A thrombin clotting time (TCT) is optional.
    • A prolonged PT is usually the first laboratory test result to be abnormal in vitamin K deficiency bleeding; however, no laboratory test result can confirm the diagnosis of vitamin K deficiency bleeding.
    • A direct blood measurement of vitamin K is not useful because levels normally are low in newborns.
    • levels of protein induced by vitamin K antagonism (PIVKA II) are increased in vitamin K deficiency bleeding, but this test is generally not available outside of research laboratories.
    • Infants with vitamin K deficiency bleeding typically have a prolonged PT with platelet counts and fibrinogen levels within the normal range for newborns. Thrombocytopenia or a prolonged aPTT should prompt workup for other causes of bleeding during the neonatal period.
  • The diagnosis of vitamin K deficiency bleeding is confirmed if administration of vitamin K halts the bleeding and reduces the PT value.

Imaging Studies

  • Intracranial bleeding is rare and usually associated with other causes of bleeding, particularly thrombocytopenia; however, intracranial hemorrhage has been reported in vitamin K deficiency bleeding and can be fatal.  
  • Investigate any neurologic symptoms with imaging. MRI exposes the neonate to no radiation and is becoming the preferred way to study the brain because tissue damage can be better defined. 

Other Tests

  • A full coagulopathy work-up and hematology consultation are required if clinical and laboratory findings are suggestive of non–vitamin K deficiency bleeding.  
  • A work-up that includes functional tests and imaging are mandatory if liver disease is suspected. 
  • Hereditary defects in the coagulation system must always be considered among the differential diagnoses.

Procedures

  • If the cause of bleeding is not straight forward, the caregiver may need to perform other procedures like endoscopic retrograde cholangiopancreatography [ERCP] to rule out hepatobiliary diseases.

Histologic Findings

  • If liver biopsy is indicated, histopathology with and without special stains or biochemical analyses may be helpful to rule out hepatitis, biliary atresia, tumors, and inherited metabolic diseases of the liver.

More on Hemorrhagic Disease of Newborn

Overview: Hemorrhagic Disease of Newborn
Differential Diagnoses & Workup: Hemorrhagic Disease of Newborn
Treatment & Medication: Hemorrhagic Disease of Newborn
Follow-up: Hemorrhagic Disease of Newborn
Multimedia: Hemorrhagic Disease of Newborn
References
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References

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  2. Gelston CF. On the etiology of hemorrhagic disease of the newborn. Arch Pediatr Adol Med. Oct 1921;22:351-7.

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Further Reading

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Keywords

hemorrhagic disease of newborn, HDN, vitamin K deficiency bleeding, VKDB, early-onset VKDB, classic VKDB coagulopathy, late-onset VKDB, GI neonatal bleeding, intracranial hemorrhage, ICH, umbilical cord bleeding, leukemia, cholestasis, intracranial hemorrhage, apnea, seizures, diarrhea, hepatitis, cystic fibrosis, celiac disease, short bowel syndrome, intestinal bacterial overgrowth, treatment, diagnosis

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Contributor Information and Disclosures

Author

Dharmendra J Nimavat, MD, FAAP, Assistant Professor of Clinical Pediatrics, Department of Pediatrics, Division of Neonatology, Southern Illinois University School of Medicine
Dharmendra J Nimavat, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics and American Association of Physicians of Indian Origin
Disclosure: Nothing to disclose.

Coauthor(s)

Michael P Sherman, MD, Professor, Department of Child Health, University of Missouri-Columbia School of Medicine; Director, Fellowship Training Program in Neonatal-Perinatal Medicine, NICU, Columbia Regional Hospital; Professor Emeritus, Department of Pediatrics, University of California, Davis, School of Medicine
Michael P Sherman, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, European Society for Paediatric Research, Perinatal Research Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

Oussama Itani, MD, FAAP, FACN, Clinical Associate Professor of Pediatrics and Human Development, Michigan State University; Medical Director, Department of Neonatology, Borgess Medical Center
Oussama Itani, MD, FAAP, FACN is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, and American Heart Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

David A Clark, MD, Chairman, Professor, Department of Pediatrics, Albany Medical College
David A Clark, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Pediatric Society, Christian Medical & Dental Society, Medical Society of the State of New York, New York Academy of Sciences, and Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Carol L Wagner, MD, Professor of Pediatrics, Medical University of South Carolina
Carol L Wagner, MD is a member of the following medical societies: American Academy of Pediatrics, American Chemical Society, American Medical Women's Association, American Public Health Association, American Society for Bone and Mineral Research, American Society for Clinical Nutrition, Massachusetts Medical Society, National Perinatal Association, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD, Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine
Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Pediatric Society, Connecticut State Medical Society, Eastern Society for Pediatric Research, and Society for Pediatric Research
Disclosure: Nothing to disclose.

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