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Hemorrhagic Disease of Newborn Treatment & Management

  • Author: Dharmendra J Nimavat, MD, FAAP; Chief Editor: Ted Rosenkrantz, MD  more...
 
Updated: Jan 02, 2016
 

Medical Care

Prevention of vitamin K deficiency bleeding (VKDB) with intramuscular vitamin K is of primary importance in the medical care of neonates. A single dose of intramuscular vitamin K after birth effectively prevents classic vitamin K deficiency bleeding. Conversely, oral vitamin K prophylaxis improves coagulation test results at 1-7 days, but vitamin K administered by this route has not been tested in randomized trials for its efficacy in preventing either classic or late vitamin K deficiency bleeding.[18, 19]

The American Academy of Pediatrics in their policy statements has endorsed the universal supplementation of vitamin K using the intramuscular injection (IM) because no vitamin K preparation is licensed for oral use in the United States.[24, 25, 26]

Immediately administer vitamin K subcutaneously (hold pressure on the site) for any infant in whom vitamin K deficiency bleeding is suspected or who has serious, unexplained neonatal bleeding. Note the following:

  • IM administration can result in a hematoma because of the coagulopathy.
  • Intravenous (IV) administration of vitamin K has been associated with anaphylactoidlike reactions.
  • Fresh frozen plasma may be considered for moderate-to-severe bleeding.
  • Life-threatening bleeding may also be treated with prothrombin complex concentrates (PCC).
  • Because the bleeding in classic vitamin K deficiency bleeding usually is not life threatening, a single dose of parenteral vitamin K is sufficient to stop the bleeding and return prothrombin time (PT) values to the reference range.
  • In the early 1990s, an association between parenteral vitamin K and the later occurrence of childhood cancer was reported; however, a large cohort study and a large retrospective analysis of a database in the United States could not confirm this association. Because this association is weak at best, routine vitamin K prophylaxis is recommended and supported by the American Academy of Pediatrics.
  • Oral vitamin K has been studied as an alternative and can improve clotting studies and vitamin K levels, but it has not been studied in large randomized controlled trials to determine if this strategy effectively prevents early and late vitamin K deficiency bleeding.

Studies from different countries have reported evidence of a rise in vitamin K prophylaxis being refused or neglected. A Canadian study, for example, found that of 282,378 children born in Alberta between 2006 and 2012, neonatal prophylaxis was declined in 0.3% of cases, with the incidence of vitamin K refusal being higher in midwife-assisted births than in physician-attended deliveries. In an Israeli study, in which questionnaires were answered by 217 expectant parents, 22.5% of participants were unaware of recommendations regarding neonatal vitamin K prophylaxis.[27, 28, 29]

Transfer

Infants with evidence of intracranial bleeding may require transfer to a level III nursery after stabilization with subcutaneous vitamin K and other aspects of supportive care.

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Surgical Care

Normally, vitamin K deficiency bleeding infants do not require surgical care but in rare cases, an infant may need neurosurgical evaluation and treatment.

Other conditions, such as those associated with short bowel syndrome and hepatobiliary disease may require surgical evaluation.

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Consultations

Vitamin K deficiency bleeding usually warrants consultation with a pediatric hematologist to rule out other causes of hemorrhagic disease of the newborn.

In such instances, close follow-up is needed after discharge from the hospital.

Pediatric surgery and pediatric neurosurgery consultation should be obtained when they are deemed necessary.

A pediatric hematologist may also be beneficial as a consultant.

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Diet

The best sources are green leafy vegetables, legumes, soybean and olive oils.

Breastfed infants should receive vitamin K supplementation; if mothers refuse prophylaxis, they should be counseled. Because breast milk is not a good source of vitamin K, infants of mothers who refuse prophylaxis and who exclusively breastfeed should have receive oral supplementation of vitamin K.[30]

A relatively recent recommendation for oral vitamin K supplementation in term infants suggests weekly administration of 1 mg until age 12 weeks or 2 mg at birth repeated at age 1 week and age 4 weeks,[31] but this recommendation emphasizes a lack of information related to dosing of oral vitamin K in preterm infants. An additional oral dose of 2 mg at age 8 weeks has also been suggested.[32]

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Activity

During acute bleeding, the infant with vitamin K deficiency bleeding should be handled with caution until the coagulation profile returns to normal after vitamin K supplementation.

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Contributor Information and Disclosures
Author

Dharmendra J Nimavat, MD, FAAP Associate 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, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

Coauthor(s)

Michael P Sherman, MD, FAAP Professor, Department of Child Health, University of Missouri-Columbia School of Medicine; Neonatologist, Women’s and Children’s Hospital; Professor Emeritus, Department of Pediatrics, University of California, Davis, School of Medicine

Michael P Sherman, MD, FAAP is a member of the following medical societies: American Pediatric Society, American Society for Microbiology, American Thoracic Society, Pediatric Infectious Diseases Society, American Association for the Advancement of Science, European Society for Paediatric Research, Western Society for Pediatric Research, Perinatal Research Society, American Academy of Pediatrics, American Association of Immunologists, Society for Pediatric Research

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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 and Dental Associations, Medical Society of the State of New York, New York Academy of Sciences, 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 Pediatric Society, Eastern Society for Pediatric Research, American Medical Association, Connecticut State Medical Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

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 Association for Physician Leadership, American Heart Association, American College of Nutrition

Disclosure: Nothing to disclose.

Acknowledgements

The authors appreciate the review of this article and helpful suggestions for improvement from Professor Daniel Batton, the Director of the Neonatology Division at Southern Illinois University School of Medicine.

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