Hemorrhage in the newborn and vitamin K prophylaxis

Haemorrhagic disease in newborn and older infants: a study in hospitalized children in Kelantan, Malaysia

This is a retrospective study of the epidemiology, clinical features, laboratory findings, treatment and outcome of haemorrhagic disease in 42 Kelantanese infants who were admitted to Hospital Universiti Sains Malaysia during a 2-year period (1987-1988). Classical haemorrhagic disease of the newborn was the commonest presentation (48%), followed by early onset (29%) and late onset (24%) disease. Home deliveries accounted for 81% of the affected infants. Most of these babies were not given vitamin K at birth in contrast to those delivered in hospitals. All except one infant were breastfed. The six commonest presenting clinical features were pallor, jaundice, umbilical cord bleeding, tense fontanelle, convulsions and hepatomegaly. All the infants had prolonged prothrombin and partial thromboplastin times which were corrected by administration of vitamin K. Subdural haemorrhage was the commonest form of intracranial haemorrhage, followed by subarachnoid haemorrhage. The overall case fatality rate was 14%. The results of this study once again emphasize the value of vitamin K prophylaxis in the newborn.

Mandating vitamin K prophylaxis for newborns in New York State

New York State's infant deaths and hospitalizations attributed to hemorrhagic disease of the newborn and other neonatal hemorrhagic conditions were reviewed. In 65% of 34 deaths reviewed, vitamin K was not documented as given or was given only after the onset of hemorrhage. Vitamin K was not included in standing orders in any of 22 hospitals contacted. As a result of this review, vitamin K prophylaxis was made a mandatory newborn care procedure in the State Public Health Code.

Vitamin K to neonates. Peroral versus intramuscular administration

In a randomized study of 300 infants, the effect of 1 mg of peroral vitamin K given at birth was compared to the same dose given as an intramuscular injection. The combined activity of coagulation factor II + VII + X taken after 48 and before 72 hours after delivery served as the primary endpoint. Prothrombin (antigen) and PIVKA II (acarboxyprothrombin) were also measured. All infants were observed for events of bleeding until discharge from the hospital, normally on the fifth day. No significant differences between the groups in any of the biochemical markers were observed. The 95% confidence limits of the differences were very narrow for all factors. No cases of bleeding were observed. We conclude that administration of 1 mg peroral vitamin K is as efficient as intramuscular administration of the same dose in the prevention of classical hemorrhagic disease of the newborn.

Vitamin K in infancy

Vitamin K has regained paediatric interest due to a recurrence of bleeding caused by deficiency of the vitamin in newborns and young infants. Increasing awareness of these clinical problems, the development of new methods for the detection of vitamin K deficiency and the direct measurement of vitamin K in tissues have stimulated research. Much new data obtained from these studies has proved helpful to the understanding of vitamin K deficiency in infancy. For example low concentrations of vitamin K have been found in fetal and neonatal livers. The implications of these findings with respect to manifest vitamin K deficiency and to new methods for detection of subclinical vitamin K deficiency are discussed. Breast-feeding is a major risk factor for classical haemorrhagic disease of the newborn and for late onset bleeding due to vitamin K deficiency in young infants. The interdependencies between breast-feeding and vitamin K deficiency are discussed on the basis of new data obtained from direct measurement of vitamin K in maternal milk. The review further focuses on pathophysiological concepts of bleeding due to vitamin K deficiency in infancy and current concepts of vitamin K prophylaxis.

Acarboxyprothrombin concentration [corrected] after oral prophylactic vitamin K

The effect of prophylaxis with oral vitamin K (1 mg vitamin K1 given with the first feed) on the rate of detection of acarboxyprothrombin (PIVKA II) and factor II clotting concentration [corrected] were analysed. Introducing such prophylaxis reduced the rates of detection of PIVKA II concentration [corrected] on day 5 from 48% to zero. None of the babies given prophylaxis had factor II clotting concentration [corrected] below 40%, compared with 34 of 95 babies not given prophylaxis. This study has important implications in the prophylaxis of both classical and late onset haemorrhagic disease of the newborn.

Vitamin K in the newborn: influence of nutritional factors on acarboxy-prothrombin detectability and factor II and VII clotting activity

The incidence of acarboxy-prothrombin and the clotting activity of factors II and VII were evaluated on the fifth day of life in 183 healthy newborns, who had received no vitamin K prophylaxis. Acarboxy-prothrombin was detected in 93/183 newborns. All acarboxy-prothrombin-negative babies had factors II and VII clotting activities above 25% whereas a great variability was observed in acarboxy-prothrombin-positive babies: 21/93 had factor II and 14/93 had factor VII activities below 25%. Seventy-two of the acarboxy-prothrombin-positive babies had normal factor II and VII clotting times on the fifth day of life. These babies must be suspected to have had vitamin K deficiency on one of the first 4 days, as acarboxy-prothrombin has a 50% disappearance rate of 50 h. Acarboxy-prothrombin was mainly observed in breast-fed infants (84/122) and only rarely detectable in infants receiving supplementary (7/44) or exclusive formula feeding (2/17). The type of milk feeding however might be less important for the babies' vitamin K supply than the actual milk intake. All acarboxy-prothrombin-positive babies had received small amounts of milk on the first 4 days of life. In those with low factor II and VII clotting activities the milk intake was low throughout the first 4 days of life, whereas babies with acarboxy-prothrombin and and normal clotting activities had increased their milk intake to more than 100 ml on the third and fourth day of life. Recommendations for vitamin K prophylaxis in newborns should be given with regard to the feeding on the first days of life.

Serum vitamin K1 concentration and vitamin K-dependent clotting factor activity in maternal and fetal cord blood

The serum concentration of phylloquinone (vitamin K1) was measured in 34 healthy mothers and in the arterial cord blood of their newborn infants. In addition, the activities of factor II and of factors VII plus X were determined simultaneously in 16 paired maternal and fetal bloods. The serum vitamin K1 concentration was similar to that of control subjects in 27 mothers: 9.03 +/- 4.9 micrograms/L (mean and SD), with a simultaneous concentration of 10.4 +/- 5.3 micrograms/L in cord blood. Six mothers exhibited high serum vitamin K1 concentrations from 40 to 240 micrograms/L (median, 82) and the concentration in cord blood ranged from 25 to 115 micrograms/L (median, 71). One mother had a normal concentration of vitamin K1: 9 micrograms/L while no vitamin K1 was detectable in the serum of her infant. The activity of factor II and factors VII plus X was 7% and 7%, respectively, in this infant and 100% in the mother. All other mothers showed normal factor II and factors VII plus X activity, while the median activity was 47% (28%-56%) for factor II and 65% (35%-100%) for factors VII plus X in cord blood. These data suggest that vitamin K1 can cross the placental barrier but not in every case. Therefore the systematic administration of vitamin K1 to the newborn infant seems to be required to prevent the occurrence of the hemorrhagic disease.

Plasma concentrations after oral or intramuscular vitamin K1 in neonates

One hundred and seven healthy, breast fed infants received 1 mg vitamin K1 either at birth (orally or intramuscularly) or with the first feed (orally). Venous blood samples collected in the next 24 hours were assayed for plasma vitamin K1. In babies given the vitamin orally at birth, the peak median concentration (73 ng/ml) occurred at four hours. By 24 hours median plasma concentrations had fallen to 23 ng/ml and 35 ng/ml in the groups fed vitamin K1 at birth or with the first feed, respectively; this difference was not, however, significant. Plasma concentrations after intramuscular injection exceeded those in the oral groups at all comparable times, with a peak median concentration of 1781 ng/ml at 12 hours falling to 444 ng/ml at 24 hours. Since median plasma vitamin K1 concentrations 24 hours after oral administration were some 100 times and 1000 times greater than previously estimated adult and newborn values respectively, this study supports giving vitamin K1 orally at birth to well, mature babies to protect against early haemorrhagic disease of the newborn. Further studies are needed to determine the optimum dose for protection over subsequent weeks.

May mothers taking acenocoumarol breast feed their infants?

In 20 women receiving Sintrom post partum, the acenocoumarol concentration in serum and breast milk at different times was measured. Even at the time of maximal serum concentration, or for the following 6 h, no acenocoumarol could be detected in the breast milk. In accordance with this finding, no effect of breast feeding on Thrombotest values of the infants could be demonstrated. These data suggest that mothers taking acenocoumarol for a short period may safely breast feed their infants.

Factor II (prothrombin) levels in cord blood: correlation of coagulant activity with immunoreactive protein

Hypoprothrombinemia occurs in newborn infants, but it is unclear whether this is the result of reduced production of Factor II precursor or a vitamin K deficient state. In this study, 76 cord blood specimens were analyzed for functional factor coagulant activity and levels of Factor II antigen as determined by electroimmunoassay. In 40 normal term infants, CA = 30% +/- 1.6 (mean +/- SEM) and Ag = 44% +/- 2.3; in 17 normal preterm infants CA = 30% +/- 1.0 and Ag = 31% +/- 4.2; and in 50 normal adults CA = 83 +/- 3 and Ag = 91 +/- 4. In the term infants the average ratio of CA:Ag was 0.90 and in the preterm infants 0.96, both values being similar to those in adults and suggesting underproduction of the precursor form. In 19 term infants who experienced complications of pregnancy and/or delivery, the ratio was 0.76; seven of these ratios were less than 0.70 (range 0.40 to 0.69). These data show that hypoprothrombinemia is common in infant cord blood and is most marked in preterm infants. In the normal infants the CA:Ag ratios were normal, suggesting that the hypoprothrombinemia is the result of reduced production of the protein and not of vitamin K deficiency. However, term infants with complications of labor and delivery had reduced CA:Ag ratios that were suggestive of vitamin K deficiency.

Coagulation defects in hypoxic full-term newborn infants

Blood clotting was examined in 24 consecutive full-term newborn infants with hypoxia and 23 normal control infants. There was evidence of a gross alteration in the clotting process in the hypoxic infants. The degree of disturbance in clotting seemed to be dependent on the severity of the hypoxia, suggesting a causal relationship. The mechanism involved seemed to be intravascular coagulation. The consumption of clotting factors involved led to the appearance of a haemorrhagic diathesis. This effect seemed to be of short duration, suggesting that direct liver damage plays at most a minor part.Though there was no evidence of damage in the infants who survived, it is possible that intravascular coagulation induced by hypoxia, by leading to deposition of fibrin, may cause damage to vital organs. Further studies will be required to examine this possibility.

Effect of asphyxia on thrombotest values in low birthweight infants

Thrombotest was used as a measure of coagulation status in 55 low birthweight infants. The initial levels were similar in both babies who were asphyxiated at birth and in those who had uncomplicated deliveries. On the other hand, 24 hours after giving vitamin K₁, a rise in the mean percentage thrombotest activity was confined to the normal delivery group. No significant rise occurred in the babies who suffered from hypoxia. It is suggested that fresh frozen plasma should be given particularly to asphyxiated low birthweight infants in an effort to diminish their liability to haemorrhage.