Medscape is available in 5 Language Editions – Choose your Edition here.


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]


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.


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.



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.



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]



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.

Contributor Information and Disclosures

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.


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.


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.

  1. Victora C. Vitamin K deficiency and haemorrhagic disease of the newborn: a public health problem in less developed countries?. UNICEF staff working papers. Feb 1997. Available at

  2. Sutor AH, von Kries R, Cornelissen EA, McNinch AW, Andrew M. Vitamin K deficiency bleeding (VKDB) in infancy. ISTH Pediatric/Perinatal Subcommittee. International Society on Thrombosis and Haemostasis. Thromb Haemost. 1999 Mar. 81(3):456-61. [Medline].

  3. Brinnhous KM, Smith HP, Warner ED. Plasma plasma prothrombin level in normal infancy and in hemorrhagic disease of the newborn. Am J Med Sci. April 1937. 193:475-81.

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

  5. Bandyopadhyay PK. Eight. Vitamins and Hormones. Elsevier Inc; 2008. Vol 78: 157-84. [Full Text].

  6. Hougie C, Barrow EM, Graham JB. Stuart clotting defect. I. Segregation of an hereditary hemorrhagic state from the heterogeneous group heretofore called stable factor (SPCA, proconvertin, factor VII) deficiency. J Clin Invest. 1957 Mar. 36(3):485-96. [Medline].

  7. Clarke P, Shearer MJ. Vitamin K deficiency bleeding: the readiness is all. Arch Dis Child. 2007 Sep. 92(9):741-3. [Medline].

  8. Pichler E, Pichler L. The neonatal coagulation system and the vitamin K deficiency bleeding - a mini review. Wien Med Wochenschr. 2008. 158(13-14):385-95. [Medline].

  9. Oldenburg J, Marinova M, Müller-Reible C, Watzka M. The vitamin K cycle. Vitam Horm. 2008. 78:35-62. [Medline].

  10. Widdershoven J, van Munster P, De Abreu R, et al. Four methods compared for measuring des-carboxy-prothrombin (PIVKA-II). Clin Chem. 1987 Nov. 33(11):2074-8. [Medline].

  11. Benno Y, Sawada K, Mitsuoka T. The intestinal microflora of infants: fecal flora of infants with vitamin K deficiency. Microbiol Immunol. 1985. 29(3):243-50. [Medline].

  12. Paiva SA, Sepe TE, Booth SL, et al. Interaction between vitamin K nutriture and bacterial overgrowth in hypochlorhydria induced by omeprazole. Am J Clin Nutr. 1998 Sep. 68(3):699-704. [Medline].

  13. Greer FR. Vitamin K status of lactating mothers and their infants. Acta Paediatr Suppl. 1999 Aug. 88(430):95-103. [Medline].

  14. von Kries R, Shearer MJ, Widdershoven J, Motohara K, Umbach G, Gobel U. Des-gamma-carboxyprothrombin (PIVKA II) and plasma vitamin K1 in newborns and their mothers. Thromb Haemost. 1992 Oct 5. 68(4):383-7. [Medline].

  15. Gibbons RJ, Engle LP. Vitamin K compounds in bacteria that are obligate anaerobes. Science. 1964 Dec 4. 146:1307-9. [Medline].

  16. Booth SL, Suttie JW. Dietary intake and adequacy of vitamin K. J Nutr. 1998 May. 128(5):785-8. [Medline].

  17. Greer FR, Mummah-Schendel LL, Marshall S, Suttie JW. Vitamin K1 (phylloquinone) and vitamin K2 (menaquinone) status in newborns during the first week of life. Pediatrics. 1988 Jan. 81(1):137-40. [Medline].

  18. Ozdemir MA, Karakukcu M, Per H, Unal E, Gumus H, Patiroglu T. Late-type vitamin K deficiency bleeding: experience from 120 patients. Childs Nerv Syst. 2012 Feb. 28(2):247-51. [Medline].

  19. Takahashi D, Shirahata A, Itoh S, Takahashi Y, Nishiguchi T, Matsuda Y. Vitamin K prophylaxis and late vitamin K deficiency bleeding in infants: fifth nationwide survey in Japan. Pediatr Int. 2011 Dec. 53(6):897-901. [Medline].

  20. Darlow BA, Phillips AA, Dickson NP. New Zealand surveillance of neonatal vitamin K deficiency bleeding (VKDB): 1998-2008. J Paediatr Child Health. 2011 Jul. 47(7):460-4. [Medline].

  21. Bellini S. What parents need to know about vitamin K administration at birth. Nurs Womens Health. 2015 Jun-Jul. 19 (3):261-5. [Medline].

  22. Hauschner H, Rosenberg N, Seligsohn U, et al. Persistent neonatal thrombocytopenia can be caused by IgA antiplatelet antibodies in breast milk of immune thrombocytopenic mothers. Blood. 2015 Jul 30. 126 (5):661-4. [Medline].

  23. Mitsiakos G, Pana ZD, Chatziioannidis I, et al. Platelet mass predicts intracranial hemorrhage in neonates with gram-negative sepsis. J Pediatr Hematol Oncol. 2015 Oct. 37 (7):519-23. [Medline].

  24. [Guideline] American Academy of Pediatrics Committee on Nutrition. Vitamin K compounds and their water soluble analogues. Pediatrics. Sept 1961. 28:501-7.

  25. [Guideline] American Academy of Pediatrics Committee on Fetus and Newborn. Controversies concerning vitamin K and the newborn. Pediatrics. 2003 Jul. 112(1 Pt 1):191-2. [Medline].

  26. American Academy of Pediatrics, Committee on Nutrition. Nutrional Needs of Preterm Infants. Ronald E. Kleinman, MD. Nutritional needs of preterm infants. In: Pediatrics Nutrition Handbook. 5th. Elk Grove Village, IL: American Academy of Pediatrics; 1998. 23-46.

  27. Sahni V, Lai FY, MacDonald SE. Neonatal vitamin k refusal and nonimmunization. Pediatrics. 2014 Sep. 134(3):497-503. [Medline].

  28. Eventov-Friedman S, Vinograd O, Ben-Haim M, et al. Parents' knowledge and perceptions regarding vitamin K prophylaxis in newborns. J Pediatr Hematol Oncol. 2013 Jul. 35(5):409-13. [Medline].

  29. Schulte R, Jordan LC, Morad A, et al. Rise in late onset vitamin K deficiency bleeding in young infants because of omission or refusal of prophylaxis at birth. Pediatr Neurol. 2014 Jun. 50(6):564-8. [Medline].

  30. Greer FR, Marshall SP, Foley AL, Suttie JW. Improving the vitamin K status of breastfeeding infants with maternal vitamin K supplements. Pediatrics. 1997 Jan. 99(1):88-92. [Medline].

  31. Van Winckel M, De Bruyne R, Van De Velde S, Van Biervliet S. Vitamin K, an update for the paediatrician. Eur J Pediatr. 2009 Feb. 168(2):127-34. [Medline].

  32. Young TE, Mangum B. Vitamins and Minerals. NEOFAX 2008. 21st edition. Montavale, NJ: Thomson Reuters; 2008. 288-9.

  33. McNinch A, Busfield A, Tripp J. Vitamin K deficiency bleeding in Great Britain and Ireland: British Paediatric Surveillance Unit Surveys, 1993 94 and 2001-02. Arch Dis Child. 2007 Sep. 92(9):759-66. [Medline].

  34. Alatas FS, Hayashida M, Matsuura T, Saeki I, Yanagi Y, Taguchi T. Intracranial Hemorrhage Associated With Vitamin K-deficiency Bleeding in Patients With Biliary Atresia: Focus on Long-term Outcomes. J Pediatr Gastroenterol Nutr. 2012 Apr. 54(4):552-7. [Medline].

Vitamin K cycle.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.