New Zealand surveillance of neonatal vitamin K deficiency bleeding (VKDB): 1998-2008

Vitamin K and the Newborn Infant

Intramuscular administration of vitamin K for prevention of vitamin K deficiency bleeding (VKDB) has been a standard of care since the American Academy of Pediatrics 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. This increase in incidence of VKDB is attributable to parental refusal as well as lowered efficacy of alternate methods of administration. The aim of this statement is to discuss the current knowledge of prevention of VKDB with respect to the term and preterm infant and address parental concerns regarding vitamin K administration.

Belgian Consensus Recommendations to Prevent Vitamin K Deficiency Bleeding in the Term and Preterm Infant

Neonatal vitamin K prophylaxis is essential to prevent vitamin K deficiency bleeding (VKDB) with a clear benefit compared to placebo. Various routes (intramuscular (IM), oral, intravenous (IV)) and dosing regimens were explored. A literature review was conducted to compare vitamin K regimens on VKDB incidence. Simultaneously, information on practices was collected from Belgian pediatric and neonatal departments. Based on the review and these practices, a consensus was developed and voted on by all co-authors and heads of pediatric departments. Today, practices vary. In line with literature, the advised prophylactic regimen is 1 or 2 mg IM vitamin K once at birth. In the case of parental refusal, healthcare providers should inform parents of the slightly inferior alternative (2 mg oral vitamin K at birth, followed by 1 or 2 mg oral weekly for 3 months when breastfed). We recommend 1 mg IM in preterm <32 weeks, and the same alternative in the case of parental refusal. When IM is perceived impossible in preterm <32 weeks, 0.5 mg IV once is recommended, with a single additional IM 1 mg dose when IV lipids are discontinued. This recommendation is a step towards harmonizing vitamin K prophylaxis in all newborns.

The challenge to define the optimal prophylactic regimen for vitamin K deficiency bleeding in infants

Infants are at risk of vitamin K deficiency that may lead to vitamin K deficiency bleeding (VKDB). Although many vitamin K prophylactic regimens have been developed throughout the years, still cases of late form VKBD may occur. The introduction of combined prophylactic strategy with prolonged oral prophylaxes after the intramuscular dose at birth has showed a decrease of the late severe VKDB incidence. Nevertheless, there is still lack of consensus about the administration scheme after the first dose at birth. CONCLUSION: Late form VKBD is not eradicated, and the best prophylactic regimen in term and preterm infants is still an open debate.

Vitamin K Deficiency Bleeding: An Ounce of Prevention

Vitamin K is a fat-soluble vitamin essential for the formation of factors in the clotting cascade. Newborns are born with insufficient levels of vitamin K, resulting in high risk for vitamin K deficiency bleeding (VKDB). Vitamin K deficiency bleeding can occur in the first week of life ("classic" VKDB) and also between 2 weeks and 3 months of age ("late" VKDB). Vitamin K deficiency bleeding can present as bleeding in the skin or gastrointestinal tract, with as many as half of affected neonates experiencing intracranial bleeding. A single intramuscular injection of vitamin K effectively prevents both classic and late VKDB. Although intramuscular vitamin K is safe and effective, VKDB has reemerged because of decreased utilization. Parents refuse intramuscular vitamin K for a variety of reasons, including a disproven association with childhood cancer, the desire to avoid exposure to additives, and valid concerns about early neonatal pain. Many parents request oral vitamin K, an inferior alternative strategy that requires multiple doses utilizing products not designed for neonatal oral administration. In this setting, health care professionals must understand the epidemiology of VKDB and compassionately counsel parents to assuage concerns. Delivery of intramuscular vitamin K to all newborns remains a public health imperative, benefitting thousands of infants annually.

Vitamin K deficiency bleeding in Australian infants 1993-2017: an Australian Paediatric Surveillance Unit study

OBJECTIVE

To undertake surveillance of vitamin K deficiency bleeding (VKDB) in Australia from 1993 to 2017, during a time of change to national recommendations and available vitamin K formulations.

METHODS

Paediatricians reported cases of VKDB in infants aged <6 months and provided demographic, clinical and biochemical information via the Australian Paediatric Surveillance Unit.

RESULTS

58 cases were reported, of which 5 (9%) were early, 11 (19%) classic and 42 (72%) late VKDB. 53 (91%) were exclusively breast fed. Seven (12%) received oral prophylaxis, the majority (86%) of whom did not receive all three recommended doses. The overall reported incidence was 0.84 per 100 000 live births (95% CI: 0.64 to 1.08) and the incidence of late VKDB was 0.61 per 100 000 live births (95% CI: 0.44 to 0.82), which are similar to rates reported by other countries where intramuscular vitamin K is recommended. VKDB rates were significantly higher (2.46 per 100 000 live births; 95% CI: 1.06 to 4.85) between 1993 and March 1994 when oral prophylaxis was recommended (p<0.05). Vitamin K was not given to 33 (57%) cases, primarily due to parental refusal, and the number of parental refusals increased significantly after 2006 (p<0.05). There were six deaths, all due to intracranial haemorrhage, and three associated with home delivery and parental refusal of vitamin K.

CONCLUSIONS

Incidence rates of VKDB in Australia are among the lowest in the world; however, we have identified an increasing trend of parental refusal. Ongoing surveillance and educational campaigns for health professionals and parents are needed to prevent VKDB.

Refusal of Intramuscular Vitamin K by Parents of Newborns: A Review

In 2019, the American Academy of Pediatrics made public education about intramuscular vitamin K administration at birth a public health priority, partly in response to reports of refusal of intramuscular vitamin K by parents of newborns that led to vitamin K deficiency bleeding (VKDB). We reviewed the literature on the frequency of, reported reasons for, and factors associated with refusal of intramuscular vitamin K, incidence of VKDB in newborns who did not receive intramuscular vitamin K, and use of oral vitamin K to prevent VKDB. Without prophylaxis, estimates of the incidence per 100 000 births of VKDB range from 250 to 1700 for early VKDB and from 10.5 to 80 for late VKDB. The frequency of refusal of intramuscular vitamin K by parents ranged from 0% to 3.2% in US hospitals, up to 14.5% in home births, and up to 31.0% in birthing centers. Reported reasons for refusal were concern of harm from the injection, a desire to be natural, and a belief in alternative methods of prophylaxis. Parents who refused intramuscular vitamin K were more likely to refuse immunizations. Many different regimens were used for orally administered vitamin K; it is not clear which is best, but all are less effective than intramuscular vitamin K. VKDB is rare but can result in either neurologic sequelae or death. In addition to continued surveillance of the frequency of both refusal of intramuscular vitamin K and VKDB, a renewed focus on education of and collaboration with parents is needed to address this major public health threat.

Countering vaccine hesitancy through immunization information systems, a narrative review

Immunization is one of the most important public health interventions to contrast infectious disease; however, many people nowadays refuse vaccination. Vaccine hesitancy (VH) is due to several factors that influence the complex decision-making process. Information technology tools might play an important role in vaccination programs. In particular, immunization information systems (IISs) have the potential to improve performance of vaccination programs and to increase vaccine uptake. This review aimed to present IIS functionalities in order to counter VH. In detail, we analyzed the automatic reminder/recall system, the interoperability of the system, the decision support system, the web page interface and the possibility to record adverse events following immunization. IIS could concretely represent a valid instrument to increase vaccine confidence, especially trust in both health-care workers and decision makers. There are not enough trials aimed to evaluate the efficacy of IIS to counter VH. Further researches might focalize on this aspect.

Newborn Vitamin K Prophylaxis: A Historical Perspective to Understand Modern Barriers to Uptake

Since its initial discovery almost a century ago, vitamin K has been labeled as both lifesaving and malignancy causing. This has led to debate of not only its use in general but also regarding its appropriate dose and route. In this article, we review through a historical lens the past 90 years of newborn vitamin K from its discovery through to its modern use of preventing vitamin K deficiency bleeding (VKDB). Although researchers in surveillance studies have shown considerable reductions in VKDB following intramuscular vitamin K prophylaxis, ongoing barriers to the universal uptake of vitamin K prophylaxis remain. Reviewing the history of newborn vitamin K provides an opportunity for a greater understanding of the current barriers to uptake that we face. Although at times difficult, improving this understanding may allow us to address contentious issues related to parental and health professional beliefs and values as well as improve overall communication. The ultimate goal is to improve and maintain the uptake of vitamin K to prevent VKDB in newborns.

Current perspectives and practices of newborn vitamin K administration in low and middle income countries

Background

Vitamin K prophylaxis can prevent vitamin K deficiency bleeding (VKDB), and current global recommendations support universal prophylactic use in newborns. Data about access to and use of vitamin K in low and middle income countries (LMIC) are scarce. To address this gap, we explored current perspectives and practices of newborn vitamin K administration in LMIC in order to better understand the barriers to more widespread coverage of this lifesaving preventative treatment.

Methods

We conducted an online survey of stakeholders involved in newborn health. We sent the survey via e-mail to 109 individuals who were based primarily in LMIC and 23 responses were received, resulting in a response rate of 21%. Respondents were generally health or development professionals from sub-Saharan Africa and Asia.

Results

Incidence rates at the country level were mostly unknown or not supported by adequate data. Many respondents (17/23) indicated that vitamin K prophylaxis is included in their national newborn care guidelines and policies, while 12 respondents indicated that administration at birth was widely practiced. Around half of respondents reported that health workers were trained in the diagnosis and treatment of VKDB. The most frequently cited barriers to more widespread vitamin K prophylaxis were (in rank order) high rates of home birth (which preclude injections that must be given by skilled health workers), lack of access to and availability of vitamin K, perception that vitamin K prophylactic treatment is not a priority among health workers, lack of vitamin K formulations appropriate for infants, cultural practices suggesting that injection at birth is not acceptable to parents, and vitamin K not being included in national guidelines and policies. There was no consensus as to the ideal formulation, respondents preferring both the current intramuscular (IM) injection and oral formulation. Reported product attributes of IM and oral formulations are summarized.

Conclusion

Prophylactic administration of vitamin K to newborns is relatively well integrated into policy at the global and country levels, but its practice is underutilized. Barriers to use are access, supply chain logistics, provider attitudes, and restrictions on the use of injections by providers at the community level. Technology innovation may offer some promise to mitigate these barriers, although advocacy and health system strengthening might be more likely to yield improved coverage. Further investigation using in-depth bottleneck analysis at the country level could help identify specific health system improvements.

Estimated costs for treatment and prophylaxis of newborn vitamin K deficiency bleeding in Tashkent, Uzbekistan

Vitamin K deficiency bleeding (VKDB) is a preventable cause of infant mortality and long-term morbidity through the world. This study aimed to demonstrate the costs of VKDB treatment estimated from the hospital records in Tashkent, Uzbekistan, as well as the prophylaxis costs for mass vitamin K medication. Subjects were 50 patients with no operation and 50 patients who had received a brain operation, consecutively enrolled from 180 cases diagnosed at Republican Research Center of Emergency Medicine in 2014. In that year, an additional 22 VKDB patients were found in Tashkent; the incidence of VKDB was 478/100,000 among 42,225 newborns. The prophylaxis costs for all newborns in Tashkent were estimated under a plausible condition. The average age at admission was 43.2 days among 100 patients (67 boys and 33 girls) with birth weight from 2,600 g to 3,800 g (3,105 g on average). The great majority of patients (92.0%) were breastfed; 89.5% in boys and 97.0% in girls. Average treatment cost per VKDB patient was 365 USD for the operated and 285 USD for the non-operated. Total expenses of the 202 patients were estimated to be 64,603 USD. A single prophylaxis was estimated to cost 1.24 USD, totaling 52,359 USD for the prophylaxis of 42,225 newborns. Since the reduction of VKDB incidence through prophylaxis is considered to be higher than 78.5% (52,359/64,603), provision of prophylaxis services would reduce the total costs of VKDB treatment in Uzbekistan, where prophylaxis is not provided.

Why do parents decline newborn intramuscular vitamin K prophylaxis?

OBJECTIVE

To explore the influencing factors and reasoning of parents who opt out of intramuscular vitamin K prophylaxis for their newborn.

DESIGN

We conducted a qualitative study with 15 families from the Otago/Southland region of New Zealand. Semistructured interviews explored their choice to opt out of intramuscular vitamin K prophylaxis and thematic analysis was used to elucidate themes that captured important aspects of this parental decision-making process.

RESULTS

Parents opt out of intramuscular vitamin K for a variety of reasons. These were clustered into three main themes: parents' beliefs and values (philosophy and spirituality), concerns about their child's welfare (pain and potential side effects) and external influencing factors (family, friends, media and health professionals). As part of a wider family hesitancy towards medical intervention, the majority of parents also raised concerns regarding other perinatal or childhood interventions.

CONCLUSION

Many factors influence parental decision making and lead to a decision to opt out of newborn intramuscular vitamin K prophylaxis. Due to strong parallels with other common childhood interventions, these findings have relevance for vitamin K prophylaxis and for other healthcare interventions in childhood.

Prevention of Vitamin K Deficiency Bleeding in Newborn Infants: A Position Paper by the ESPGHAN Committee on Nutrition

Vitamin K deficiency bleeding (VKDB) due to physiologically low vitamin K plasma concentrations is a serious risk for newborn and young infants and can be largely prevented by adequate vitamin K supplementation. The aim of this position paper is to define the condition, describe the prevalence, discuss current prophylaxis practices and outcomes, and to provide recommendations for the prevention of VKDB in healthy term newborns and infants. All newborn infants should receive vitamin K prophylaxis and the date, dose, and mode of administration should be documented. Parental refusal of vitamin K prophylaxis after adequate information is provided should be recorded especially because of the risk of late VKDB. Healthy newborn infants should either receive 1 mg of vitamin K1 by intramuscular injection at birth; or 3 × 2 mg vitamin K1 orally at birth, at 4 to 6 days and at 4 to 6 weeks; or 2 mg vitamin K1 orally at birth, and a weekly dose of 1 mg orally for 3 months. Intramuscular application is the preferred route for efficiency and reliability of administration. The success of an oral policy depends on compliance with the protocol and this may vary between populations and healthcare settings. If the infant vomits or regurgitates the formulation within 1 hour of administration, repeating the oral dose may be appropriate. The oral route is not appropriate for preterm infants and for newborns who have cholestasis or impaired intestinal absorption or are too unwell to take oral vitamin K1, or those whose mothers have taken medications that interfere with vitamin K metabolism. Parents who receive prenatal education about the importance of vitamin K prophylaxis may be more likely to comply with local procedures.

Reasons for Refusal of Newborn Vitamin K Prophylaxis: Implications for Management and Education

OBJECTIVE

The American Academy of Pediatrics recommends intramuscular (IM) vitamin K prophylaxis for all newborns to prevent vitamin K deficiency bleeding. Given the serious implications of late-onset vitamin K deficiency bleeding, our objective was to examine factors influencing parents' decisions to refuse IM vitamin K prophylaxis.

METHODS

Parents intending to refuse IM vitamin K prophylaxis at delivery were recruited from 5 community hospitals, 1 academic medical center, and 2 birthing centers in a single Southeastern state. Participants completed a written survey including demographics, birth and parenting decisions (eg, breastfeeding), and open-ended questions about their vitamin K information sources, concerns, and knowledge of risks.

RESULTS

The incidence of refusal was highest at the birthing centers. Fifty-four parents intending to refuse IM vitamin K completed the survey. Most were white (78%), over age 30 (57%), and college graduates (65%). All reported intention to exclusively breastfeed. Most refused hepatitis B vaccine (90%) and erythromycin eye ointment (77%). The most common source of information was the Internet (70%). Concerns included synthetic or toxic ingredients (37%), excessive dose (28%), and side effects (24%). Eighty-three percent of parents reported awareness of risks associated with vitamin K refusal. However, only 6 parents (11%) decided to accept IM prophylaxis.

CONCLUSIONS

This study provides an understanding of the concerns, mindset, and information sources used by parents refusing IM vitamin K. Educating parents about the importance of IM prophylaxis should begin in the prenatal period and must address concerns parents identify on the Internet.

Declining newborn intramuscular vitamin K prophylaxis predicts subsequent immunisation refusal: A retrospective cohort study

AIM

Low rates of childhood immunisation are linked to outbreaks of infectious disease. Identifying and addressing barriers to immunisation may lead to improved immunisation rates. Immunisation and newborn vitamin K prophylaxis have many similarities. We aimed to investigate whether parents who decline newborn vitamin K are also more likely to decline subsequent childhood immunisations.

METHODS

We undertook a retrospective cohort study, examining the relationship between vitamin K administration and immunisation uptake by parents of babies born over a 2-year period (January 2010-December 2011) in Dunedin, New Zealand (NZ). Both written and electronic data from a single birthing unit and the NZ National Immunisation Register (NIR) were analysed to ascertain the relationship between declining newborn vitamin K prophylaxis and subsequent immunisation uptake.

RESULTS

Records for 3575 babies were examined. Ninety-two per cent of infants received intramuscular, and 5% received oral vitamin K. An increased risk ratio for non-immunisation of 14.1 (95% confidence interval 7.8-25.9) for babies whose parents declined vitamin K was identified. Receiving oral vitamin K was also associated with subsequent non-immunisation, with a risk ratio of 3.5 (95% confidence interval 1.7-7.3).

CONCLUSIONS

Parents who decline newborn vitamin K are more likely to decline immunisation for their child. These parents, as well as those that elect for oral vitamin K, are a small but easily identifiable group to whom additional education about the benefits of immunisation could be offered. This is especially pertinent at a time when there is a resurgence of immunisation preventable diseases.

Early-onset neonatal group B streptococcus sepsis following national risk-based prevention guidelines

BACKGROUND

Neonatal infection with group B streptococcus (GBS) is an important cause of infant mortality. Intrapartum antibiotics reduce early-onset GBS sepsis, but recommendations vary as to whether they should be offered following antenatal screening or based on risk factors alone. We aimed to determine the incidence of early-onset GBS sepsis in New Zealand five years after the publication of national risk-based GBS prevention guidelines.

MATERIALS AND METHODS

Prospective surveillance of early-onset GBS sepsis (defined as infection in the first 48 h of life) was undertaken between April 2009 and March 2011 through the auspices of the New Zealand Paediatric Surveillance Unit as part of a survey of infection presenting in the first week of life.

RESULTS

There were 29 cases of confirmed early-onset GBS sepsis, including one case of meningitis, giving an incidence rate of 0.23 per 1000 (95% CI 0.16-0.33) live births. Three infants (10.3%) died. In 16 cases (55%), a maternal risk factor qualifying the mother for intrapartum antibiotics was present, but only five (31%) received this intervention. A retrospective review of the major hospital laboratory databases for this period identified two additional cases. A secondary sensitivity analysis taking account of these cases provided an estimated national incidence of 0.26 (95% CI 0.18-0.37) per 1000 live births.

CONCLUSIONS

Ten years after a similar survey and five years after promoting a single, risk-based prevention protocol nationally, the incidence of early-onset GBS disease in New Zealand has more than halved, but opportunities remain to further reduce the rate.

Neonatal Prophylaxis: Prevention of Vitamin K Deficiency Haemorrhage and Neonatal Ophthalmia

Introduction

The aim of the study was to explore two aspects of neonatal prophylaxis: the application of the vitamin K injection to the newborns and the prophylaxis against chlamydial and gonococcal eye infections, comparing Slovenian and Croatian practices.

Methods

A causal non-experimental method of quantitative empirical approach was used. The data was collected by means of predesigned questionnaires. The questionnaires were sent to 14 Slovenian and 32 Croatian birth hospitals. The data was analysed with descriptive statistics and the Kullback test.

Results

Vitamin K is applied to all newborns in 9 (out of 14) Slovene and 22 (out of 32) Croatian birth hospitals that returned the questionnaire. The prophylaxis against chlamydial gonococcal eye infections is applied to all newborns in 9 Slovene and 16 Croatian birth hospitals that offered answers to the questionnaire. The majority of Slovene and Croatian birth hospitals perform these procedures in the first hour after birth. The majority of Slovene birth hospitals still apply vitamin K in the gluteal muscle, whereas the majority of Croatian birth hospitals usually use the thigh as an injection site. In Slovenia, 1 % Targesin is used for the prophylaxis against chlamydial and gonococcal eye infections, whereas in Croatia the prevailing medicine is Erythromycin.

Conclusions

The possibility of oral vitamin K application should be offered to parents, and pain management in practice should be discussed. The form of written informed consent could be offered to parents. Health professionals should provide intimacy and exclude routine procedures in the first couple of hours after birth. However, more research is needed as delayed administration might be related to lower efficacy and, as a consequence of that, the safety of newborns is questionable.

International normalized ratio testing with point-of-care coagulometer in healthy term neonates

Background

Neonates routinely receive vitamin K to prevent vitamin K deficiency bleeding, which is associated with a high mortality rate and a high frequency of neurological sequelae. A coagulation screening test might be necessary to detect prophylactic failure or incomplete prophylaxis. However, venous access and the volume of blood required for such testing can be problematic. CoaguChek XS is a portable device designed to monitor prothrombin time while only drawing a small volume of blood. Although the device is used in adults and children, studies have not been performed to evaluate its clinical utility in neonates, and the reference value is unknown in this population. The objectives of the present study were to determine the reference intervals (RIs) for international normalized ratio (INR) using the CoaguChek XS by capillary puncture in healthy term neonates, to evaluate factors that correlate with INR, and to evaluate the device by assessing its ease of use in clinical practice.

Methods

This study included 488 healthy term neonates born at a perinatal center between July 2012 and June 2013. The INRs determined by CoaguChek XS were measured in 4-day-old neonates.

Results

The enrolled neonates were orally administered vitamin K 6-12 h after birth. A RI for INRs in 4-day-old neonates was established using the CoaguChek XS with a median value of 1.10 and a range of 0.90–1.30. A significant difference in the INR was noted between male (median value, 1.10; RI, 0.90–1.30) and female (median value, 1.10; RI, 0.90–1.24) neonates (p = 0.049). The INR was found to correlate with gestational age, birth weight, and hematocrit value.

Conclusions

The CoaguChek XS device is safe, fast, and convenient for performing INR assays in neonates. Our study is the first to establish a RI for INRs that were measured using the CoaguChek XS in healthy term neonates.

Medical and midwifery attitudes towards vitamin K prophylaxis in New Zealand neonates

AIM

Neonates are at risk for potentially life-threatening vitamin K deficiency bleeding. This can be readily prevented with prophylactic vitamin K following delivery. In this context, most vitamin K-deficiency bleeding occurs in those whose parents decline newborn vitamin K. One factor influencing parental decision-making is information received from health professionals. This study examined attitudes and perceptions towards newborn vitamin K in relevant health-care professionals.

METHODS

A literature review and one-on-one semi-structured interviews were conducted to inform questionnaire design. Midwives and selected medical staff employed in the South Island of New Zealand were then invited to complete an anonymous survey exploring attitudes and perceptions towards vitamin K prophylaxis in newborns.

RESULTS

The survey achieved an overall response rate of 57%. Almost all responding medical staff and 76% of midwives agreed with the current New Zealand Ministry of Health vitamin K guideline. All medical staff but only 55% of midwives feel that all babies should receive vitamin K. Differences were also seen between professionals with respect to vitamin K education and risks.

CONCLUSION

This is the first study to examine attitudes and perceptions of midwives and doctors to vitamin K prophylaxis in neonates. Considerable discrepancies in attitude are evident, and in some midwives, a lack of confidence in this intervention is apparent. How this affects education to families is unknown. Increased understanding of this phenomenon, along with improved education and communication to professionals and families, is required.

Prevention of vitamin K deficiency bleeding with three oral mixed micellar phylloquinone doses: results of a 6-year (2005-2011) surveillance in Switzerland

In 2003, the Swiss guidelines to prevent vitamin K deficiency bleeding (VKDB) were adapted. As two oral doses (2 mg, hour/day 4) of mixed micellar VK preparation had failed to abolish late VKDB, a third dose (week 4) was introduced. This report summarizes the new guidelines acceptance by Swiss pediatricians and the results of a prospective 6-year surveillance to study their influence on the incidence of VKDB. The new guidelines acceptance by Swiss pediatricians was evaluated by a questionnaire sent to all pediatricians of the Swiss Society of Paediatrics. With the help of the Swiss Paediatric Surveillance Unit, the incidence of VKDB was monitored prospectively from July 1, 2005 until June 30, 2011. Over a 6-year period (458,184 live births), there was one case of early and four cases of late VKDB. Overall incidence was 1.09/10(5) (95 % confidence intervals (CI) 0.4-2.6). Late VKDB incidence was 0.87/10(5) (95 % CI 0.24-2.24). All four infants with late VKDB had an undiagnosed cholestasis at the time of bleeding; parents of 3/4 had refused VK prophylaxis, and in 1/4, the third VK dose had been forgotten. Compared with historical control who had received only two oral doses of mixed micellar VK (18 cases for 475,372 live births), the incidence of late VKDB was significantly lower with three oral doses (Chi(2),Yates correction, P = 0.007).

CONCLUSION

VKDB prophylaxis with 3 × 2 mg oral doses of mixed micellar VK seems to prevent adequately infants from VKDB. The main risk factors for VKDB in breast-fed infants are parental VK prophylaxis refusal or an unknown cholestasis.

Maternal and infant characteristics by mode of vitamin K prophylaxis administration

AIM

  The aim of this study was to compare maternal and infant characteristics by mode of VK administration.

METHODS

  De-identified computerised birth files of all babies born in New South Wales (NSW), Australia between January 2007 and December 2009 (when VK prophylaxis was measured) were included in the present study. The outcome variable, mode of VK prophylaxis, was recorded by checkbox as oral, IM injection, none or not stated.

RESULTS

  We analysed population-based birth data from 2007 to 2009 in NSW, Australia and found that IM injection was the most prevalent mode of administration (96.3%, n = 263, 555), followed by oral (2.6%, n = 7023) and none (1.2%, n = 3136). Compared to neonates receiving IM VK, those with oral or none were more likely to have vaginal births without medical interventions at birth centres or planned home births and were less likely to receive hepatitis B vaccination. Among neonates administered oral VK, a larger proportion were preterm births and breastfed at discharge compared to neonates administered VK as an IM injection. Neonates with no VK recorded were more likely to be admitted to neonatal intensive care, but may have received VK later in the birth admission.

CONCLUSIONS

  A small proportion of the Australian neonates may be at risk of inadequate protection from VKBD due to parental concerns about the safety of IM injection of VK to neonates.