Administration of vitamin K for prevention of vitamin K deficiency bleeding (VKDB), formerly known as hemorrhagic disease of the newborn, has been a standard of care since the AAP recommended it in 1961. Despite the success of prevention of VKDB with vitamin K administration, the incidence of VKDB appears to be on the rise. Infants may present with a spectrum of disease from cutaneous bruising to life-threatening intracranial hemorrhage.
A new AAP policy statement reviews knowledge on prevention of VKDB and addresses parental concerns regarding vitamin K administration.
The policy Vitamin K and the Newborn Infant, from the Committee on Fetus and Newborn, Section on Breastfeeding and Committee on Nutrition, is available at https://doi.org/10.1542/peds.2021-056036 and will be published in the March issue of Pediatrics.
Vitamin K deficiency bleeding
Early-onset VKDB begins within the first 24 hours of age. It usually occurs in babies whose mothers are taking medications that affect vitamin K metabolism. These medications include anticonvulsants, antibiotics, antituberculosis agents and warfarin. Prenatal vitamin K supplementation to these mothers has not been shown to reduce early-onset VKDB.
Classic VKDB occurs between 2 days and 1 week of life. Although some cases may occur in infants whose mothers were taking medications affecting vitamin K metabolism, most cases are idiopathic. Universal vitamin K prophylaxis can eliminate the risk of classic VKDB.
Late-onset VKDB occurs between 1 week and 6 months of age, with a peak incidence between 2 and 8 weeks. Late-onset VKDB often is associated with exclusively breastfed infants who did not receive vitamin K prophylaxis at birth. Breast milk, which is the preferred nutrition for all infants, provides relatively low levels of vitamin K, making exclusively breastfed infants particularly at risk.
VKDB also may be associated with liver dysfunction secondary to neonatal hepatitis, bile duct atresia or intestinal malabsorption.
Oral vitamin K prophylaxis is not as effective as intramuscular (IM) vitamin K to prevent late-onset VKDB; thus, it cannot be recommended.
Addressing parents’ concerns
In recent years, there has been an increase in the number of parents who refuse IM vitamin K for their newborn and a resultant increase in the number of cases of late-onset VKDB. Assessing and responding to parental concerns regarding vitamin K are important roles for the pediatric provider. The discussion should be tailored to the parent’s level of understanding and cover the known benefits as well as perceived risks.
The policy statement makes the following recommendations:
- Vitamin K should be administered to all newborns weighing more than 1,500 grams (g) as a single, intramuscular dose of 1 milligram within six hours of birth.
- Preterm infants weighing ≤1500 g should receive a vitamin K dose of 0.3 milligrams/kilogram (mg/kg) to 0.5 mg/kg as a single, intramuscular dose. A single intravenous dose of vitamin K for preterm infants is not recommended for prophylaxis.
- Pediatricians and other health care providers must be aware of the benefits of vitamin K administration as well as the risks of refusal and convey this information to the infant’s caregivers.
- VKDB should be considered when evaluating bleeding in the first six months of life even in infants who received prophylaxis and especially in exclusively breastfed infants.
Dr. Hand is a lead author of the policy statement and a member of the AAP Committee on Fetus and Newborn.
- An appendix in the policy statement at https://doi.org/10.1542/peds.2021-056036 has 10 points for talking with parents about the importance of vitamin K administration.
- Information on vitamin K for parents from HealthyChildren.org
- Resources on vitamin K deficiency bleeding from the Centers for Disease Control and Prevention