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Hemorrhagic Disease of Newborn Workup

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

Laboratory Studies

Coagulations 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.

Note the following:

  • 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. For example, maternal transfer of antiplatelet antibodies in mothers with immune thrombocytopenia via breastfeeding may be associated with persistent neonatal thrombocytopenia.[22]

The diagnosis of vitamin K deficiency bleeding is confirmed if administration of vitamin K halts the bleeding and reduces the PT value.

Median platelet count and platelet mass have been reported to be significantly associated with intracranial hemorrhage in neonates at days 1, 2, and 3 after diagnosis of gram-negative sepsis.[23]

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.

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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.

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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,21tumors, and inherited metabolic diseases of the liver.

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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.

Neonatal sepsis due to gram-negative bacteria (eg, Enterobacter species) is also a cause of intracranial bleeding.[23]

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.

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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.

References
  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 http://www.unicef.org/spanish/evaldatabase/files/Global_1997_Vitamin_K.pdf.

  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].

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