Factors Associated With Refusal of Intramuscular Vitamin K in Normal Newborns

Uptake of intra-muscular vitamin K administration after birth: A national cohort study

AIM

A long-acting monoclonal antibody against RSV (nirsevimab), given as an injection shortly after birth, is currently being rolled out globally. Carer acceptance of intra-muscular (IM) vitamin K, another injection given shortly after birth, could serve to indicate the acceptability of nirsevimab.

METHODS

We analysed a national dataset of postnatal health visitor visits in Scotland; individual-level data on gestation were not available. The primary outcome measure was the modality of administration of vitamin K; potential explanatory variables were maternal age, infant ethnicity, English as a first language, and measures of socio-economic deprivation. We examined associations between IM vitamin K administration or oral/no vitamin K and each explanatory variable.

RESULTS

From 2019 to 2021, questionnaires were available for 142 857 infants; data was missing for 2.7%. IM Vitamin K uptake was high: 95.5% of carers consented, with 1.1% requesting oral vitamin K and 0.9% refusing vitamin K altogether. Infant ethnicity, use of English as a first language, socio-economic status and maternal age were not associated with reduced uptake of IM vitamin K.

CONCLUSION

If IM Vitamin K administration is a valid proxy measure for nirsevimab acceptance, we did not identify groups that might require increased engagement prior to nirsevimab roll-out.

Newborn medication adherence and childhood under-immunization in military beneficiaries

BACKGROUND

The American Academy of Pediatrics recommends birth doses of vitamin K, erythromycin ointment, and the hepatitis B vaccine, but the relationship between birth medication administration and childhood immunization compliance is understudied. The objective of this study is to evaluate rates of newborn medication administration, and risk factors for refusal in military beneficiaries and determine the relationship between medication refusal and under-immunization at 15 months.

METHODS

A retrospective chart review was completed for all term and late preterm infants born at Brooke Army Medical Center, San Antonio, TX, from January 1, 2016, to December 31, 2019. The electronic medical record was queried for birth medication administration, maternal age, active-duty status, rank, and birth order. Childhood immunization records were extracted for all patients who continued care at our facility. A patient was considered completely immunized if they had received at least 22 vaccines by 15 months: three doses of the hepatitis B vaccine [Pediarix^TM], two doses of the rotavirus vaccine [Rotarix^TM], four doses of the DTAP vaccine [Pediarix^TM and Acel-Immune^TM], three doses of Haemophilus influenza B vaccine [Pedvaxhib^TM], four doses of pneumococcal [Prevnar 13^TM], three doses of IPV [Pediarix^TM], one dose of measles, mumps, and rubella [MMR^TM], one dose of varicella [Varivax^TM] and one dose of hepatitis A vaccine [Harvix^TM].

RESULTS

Seven thousand one hundred and forty infants were included; 99.3% received vitamin K, 98.8% received erythromycin ointment, and 93.8% received the hepatitis B vaccine. Refusal of the erythromycin ointment and hepatitis B vaccine was associated with older maternal age and higher birth order. Childhood immunization records were available for 607 infants; 7.2% (n = 44) were under-immunized by 15 months, with no infants being non-immunized. Refusal of the hepatitis B vaccine (RR: 2.9 (CI 1.16-7.31)) only at birth was associated with a higher risk of being under-immunized.

CONCLUSIONS

Refusal of the hepatitis B vaccine in the nursery is associated with a risk of being under-immunized in childhood. Obstetric and pediatric providers should be aware of this association for appropriate family counseling.

A conceptual model on caregivers' hesitancy of topical fluoride for their children

BACKGROUND

Topical fluoride hesitancy is a well-documented and growing public health problem. Despite extensive evidence that topical fluoride is safe and prevents tooth decay, an increasing number of caregivers are hesitant about their children receiving topical fluoride, leading to challenges in clinical settings where caregivers refuse preventive care.

PURPOSE

To explore the determinants of topical fluoride hesitancy for caregivers with dependent children.

METHODS

In this qualitative study, we interviewed 56 fluoride-hesitant caregivers to develop an inductive conceptual model of reasons why caregivers are hesitant.

RESULTS

The core construct of the conceptual model of topical fluoride hesitancy centered on caregivers "wanting to protect and not mess up their child". Six domains comprised this core construct: thinking topical fluoride is unnecessary, wanting to keep chemicals out of my child's body, thinking fluoride is harmful, thinking there is too much uncertainty about fluoride, feeling pressured to get topical fluoride, and feeling fluoride should be a choice.

CONCLUSIONS

Topical fluoride hesitancy is complex and multifactorial. Study findings provide insight for future efforts to understand and optimize caregivers' preventive care decision making.

Midwives' Perspectives about Vitamin K Prophylaxis Against Vitamin K Deficiency Bleeding of the Newborn

BACKGROUND

The American Academy of Pediatrics recommends one intramuscular (IM) vitamin K injection at birth to prevent Vitamin K Deficiency Bleeding of the Newborn (VKDB). Among factors associated with IM vitamin K refusal, investigators have reported an increased frequency of IM vitamin K refusal among parents who select midwife-assisted deliveries. Reasons behind this association are unclear.

METHODS

To understand the perspectives of midwives on IM vitamin K prophylaxis and approach to counseling parents using qualitative methodology, we conducted in-depth semi-structured interviews of midwives associated with 3 tertiary academic medical centers and surrounding communities in Connecticut, Iowa and Michigan. We used the grounded theory approach and the constant comparative method until saturation was reached.

RESULTS

We interviewed 19 white female midwives from different training pathways. Participants who were Certified Nurse Midwives (CNMs) routinely recommended IM vitamin K prophylaxis and Certified Professional Midwives (CPMs) took a more neutral approach. The following 4 themes emerged: (1) Emphasis on an educational approach to counseling that supports parents' decision-making authority; (2) Low-intervention philosophy in the midwifery model of care attracts certain parents; (3) Need for relationship building between midwives and pediatricians and (4) Opportunities for the future.

CONCLUSIONS

Midwives in our study perceived that the midwifery model of care, the focus on physiologic birth and prioritizing parents' decision-making autonomy appears to attract a sub-set of expectant parents with certain belief systems who question interventions such as IM vitamin K prophylaxis. There are opportunities for better collaboration between midwives and pediatricians.

Prevalence and factors associated with vitamin K prophylaxis utilization among neonates in rural Ethiopia in 2016

BACKGROUND

Neonatal Mortality Ratio (NMR) could not be reversed sufficiently in Ethiopia in the last couple of years. Neonatal bleeding is one of the major causes of neonatal deaths. Administration of vitamin K prophylaxis at birth is the proven strategy to reduce neonatal death which can be caused by vitamin K deficiency bleeding. Although World Health Organization (WHO) recommends universal supplementation of vitamin K prophylaxis for all neonates at birth, many neonates could not get it in many resource poor countries. Despite its importance, information is scarce about uptake of vitamin K prophylaxis in Ethiopia in 2016. Therefore, this study aimed to identify prevalence and factors associated with vitamin K prophylaxis utilization among neonates in Ethiopia in 2016.

METHODS

Secondary data analysis of EDHS 2016 was done to assess prevalence and predictors of vitamin K prophylaxis among neonates in Ethiopia five years before EDHS 2016. Multi-stage cluster sampling was used in EDHS 2016. Sample weight and complex analysis were used to minimize bias. Bivariate and multivariable logistic regression analyses were carried out to identify factors associated with vitamin K prophylaxis. Finally, adjusted odds ratio with 95% confidence interval was calculated and P-value less than 0.05 taken as the cuff of point for declaration of the statistical significant association.

RESULTS

Prevalence of vitamin K prophylaxis among neonates in Ethiopia in 2016 was found to be 4710(65.5%) in this study. Factors like: Institutional delivery (AOR = 2.2, 95%CI: 1.8, 2.7), neonates from richest family (AOR = 2.1, 95%CI: 1.6, 2.7), neonates from richer household (AOR = 1.4, 95%CI: 1.1, 1.8), starting of antenatal care from 3-6 months of gestational age (AOR = 2.9, 95%CI: 2.3, 3.6) were factors positively associated with vitamin K prophylaxis in Ethiopia.

CONCLUSION AND RECOMMENDATION

Compared with expected world health organization recommendation of universal supplementation vitamin K prophylaxis, vitamin K utilization is lower among neonates in this study. Hence, it is recommended that strengthen early antenatal care initiation and improving community awareness about vitamin K prophylaxis are the key interventions to improve its uptake. Furthermore, improving institutional delivery might increase uptake of vitamin K prophylaxis.

Physicians’ Opinion and Practice of Vitamin K Administration at Birth in Romania

(1) Background. Vitamin K is recommended worldwide as a standard of care for the prophylaxis of vitamin-K-deficiency bleeding (VKDB). This is also a standard practice in Romania, but due to the rising number of refusals by parents of basic interventions in the neonatal period, we aimed to assess the Romanian neonatologists’ opinions and current practice regarding vitamin K administration at birth. (2) Methods. We designed and conducted an electronic survey addressed to 110 physicians working in Romanian hospitals. (3) Results. Half of respondents are accustomed to receiving refusals for vitamin K administration once or twice a year. When parents refuse vitamin K administration, they usually refuse other neonatal interventions, according to 90.9% of the responding physicians, and this situation has occurred more frequently during the last two years. The number of refusals and especially their increase are more frequent in level III hospitals (p = 0.0304, p = 0.0036, respectively). Only 22.7% of the physicians responded that they would recommend an oral preparation of vitamin K in the absence of intramuscular prophylaxis. (4) Conclusion. Efforts should be made to address parents’ concerns and to have available alternatives to the intramuscular administration of vitamin K.

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.

Improving Compliance With Revised Newborn Hepatitis B Vaccination Policy

BACKGROUND

In September 2017, the American Academy of Pediatrics issued guidance recommending hepatitis B vaccine be administered to well newborns with birth weight ≥2000 g within 24 hours after birth. At that time, ∼85% of well newborns were vaccinated before discharge at our center; however, only 35% were vaccinated within 24 hours after birth. Our aim was to vaccinate 70% of eligible newborns within 24 hours after birth by June 2018 while maintaining the overall rate of vaccination.

METHODS

A multidisciplinary improvement team analyzed existing vaccine administration processes in the well-newborn nursery. From October 2017 to January 2018, changes were made to activation of vaccine orders and to obtaining and documenting the consent processes. Vaccine administration was bundled with routine care given ≤24 hours after birth, and parent scripting was changed from offering vaccine as an option to stating it as a recommendation. From November 2016 to June 2019, we determined the overall rate and timing of vaccination using statistical process control methods.

RESULTS

Among 10 887 eligible infants, the proportion administered hepatitis B vaccine ≤24 hours after birth increased from 35.5% to 78.8% after process changes with special-cause variation on process control charts. Proportion of infants receiving vaccine any time before discharge also increased from 86.5% to 92.3%.

CONCLUSIONS

Specific process changes allowed our birth center to comply with the recommended timing for hepatitis B vaccination of ≤24 hours after birth among eligible newborns.

Variation in Newborn Skincare Policies Across United States Maternity Hospitals

OBJECTIVE

Newborn skincare influences levels of beneficial factors from vernix and vaginal secretions but also the emergence of potential skin pathogens. However, evidence-based national guidelines for newborn skincare do not exist, and actual hospital practices for newborn skincare have not been described. In this study, we test the hypothesis that US maternity hospitals follow differing policies with regard to newborn skincare.

METHODS

A 16-question survey querying skin care practices was distributed to nursery medical directors at the 109 US hospital members of the Better Outcomes through Research for Newborns network. Data from free text responses were coded by 2 study personnel. Survey responses were analyzed by using descriptive statistics and compared by region of the United States.

RESULTS

Delaying the first newborn bath by at least 6 hours is a practice followed by 87% of US hospitals surveyed. Discharging newborns without a bath was reported in 10% of hospitals and was more common for newborns born in nonacademic centers and on the West Coast. Procedures and products used for newborn skincare varied significantly. Parental education on tub immersion and soap use was also inconsistent and potentially contradictory between providers. Evidence cited by hospitals in forming their policies is scant.

CONCLUSION

In this study, we identify similar and strikingly different newborn skincare policies across a national network of US maternity hospitals. Research is needed to identify effects of differing skincare routines on skin integrity, infection rates, and childhood health outcomes to improve the evidence base for the care of newborn skin.

Trends in and Documentation of Refusal of Common Routine Newborn Interventions: 2013-2019

BACKGROUND

Refusals of intramuscular (IM) vitamin K, ocular prophylaxis, and hepatitis B vaccine (HBV) during the birth hospitalization continue to occur. Refusal of IM vitamin K increases the risk of life-threatening vitamin K deficiency bleeding. Trends in refusal rates and how well clinicians document IM vitamin K refusal is unknown.

METHODS

We reviewed charts of livebirths admitted to 5 well newborn units from 2013 to 2019. We report trends in rates of refusal and documentation of no IM vitamin K by clinicians during the birth hospitalization and within the first 6 months of life at emergency department (ED) visits.

RESULTS

Of 67 750 live births, 283 (0.4%) did not receive IM vitamin K, and 1645 (2.4%) did not receive ocular prophylaxis. Rates of IM vitamin K refusal increased slightly over time (P < .05). For HBV, 7551 (11.1%) did not receive the birth dose, but refusal rates decreased from 16.1% to 8.7% (P < .0001). Of 283 newborns who did not receive IM vitamin K, refusal was documented in 49.8% of discharge summaries, 17 (6%) had an invasive procedure without documentation of IM vitamin K administration, and 30 (10.6%) infants <6 months old had ED visits. A total of 4 infants were evaluated for potential bleeding, and there was no documentation about IM vitamin K prophylaxis.

CONCLUSION

Refusal rates of IM vitamin K and ocular prophylaxis remained low, and uptake of HBV increased over time. Documentation of IM vitamin K refusal by clinicians during the birth hospitalization, before invasive procedures, and in ED visits can be improved.

The Term Newborn: Alternative Birth Practices, Refusal, and Therapeutic Hesitancy

The care of late preterm and term newborns delivered in hospital settings in the United States is largely standardized with many routine interventions and screenings that are evidence-based and serve to protect newborn's and the public's health. Refusals of various aspects of routine newborn care are uncommon but can be challenging for clinicians who care for newborns to navigate for many reasons. In this article, we describe the spectrum of refusal. We review suggested approaches that clinicians can take starting with increasing their own awareness of what specific components of newborn care are refused and why.

Educating Parents on Vitamin K Prophylaxis for Newborns

Vitamin K is important in the clotting cascade, and vitamin K prophylaxis is important in preventing vitamin K deficiency bleeding (VKDB) in newborns. Breastfed newborns have been found to be particularly vulnerable to VKDB. Although oral vitamin K is available, there is no version for newborns approved by the U.S. Food and Drug Administration (FDA), and if a dose is missed, the risk of VKDB may more than double. Therefore, an injection is recommended by the American Academy of Pediatrics to prevent VKDB in newborns. Nurses often administer the newborn vitamin K injection, and they play a key role in educating parents and helping them make informed decisions about vitamin K prophylaxis for their newborns.

Applying lessons from vaccination hesitancy to address birth dose Vitamin K refusal: Where has the trust gone?

Refusal of intramuscular Vitamin K at birth is an emerging public health issue resulting in increased rates of intracranial bleeding. Parents who refuse this intervention bear epidemiologic resemblance to vaccine-refusing parents, are geographically clustered and share a mistrust of public health interventions. We review the prevalence of Vitamin K refusal and discuss individual and societal recommendations that may reduce Vitamin K refusal, adapted from vaccine hesitancy literature. We note the prevalence of misinformation on social media as a contributor to refusal and explore how changes in healthcare practices may influence growing physician mistrust. We propose solutions to the issue including state-based mandates and a pervasive social media strategy to combat misinformation as a contributor to Vitamin K refusal.

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.

Oral Vitamin K Prophylaxis in Newborns: A Survey of Clinician Opinions and Practices

OBJECTIVES

The majority of newborns in the United States receive intramuscular (IM) vitamin K for prophylaxis against vitamin K deficiency bleeding (VKDB). Oral vitamin K is less effective than IM vitamin K in preventing VKDB but is widely used in Europe and by some in the United States when parents refuse IM vitamin K for their newborn. Our aim was to assess the practices, opinions, and knowledge of newborn clinicians regarding oral vitamin K prophylaxis when parents refuse IM vitamin K.

METHODS

We conducted an electronic survey of newborn clinicians from 3 academic medical centers in California, Iowa, and Connecticut. Descriptive statistics and χ² tests were performed.

RESULTS

Of 160 newborn clinicians at 3 sites, 110 (69%) completed the survey. Of respondents, 58 (53%) believed the incidence of IM vitamin K refusal is increasing and had prescribed or recommended oral vitamin K at least once. Regarding knowledge, 32 (28%) and 23 (20%) respondents did not know whether oral vitamin K decreases the risk of early- and late-onset VKDB, respectively. There were no significant differences in opinions, knowledge, or practices across institutions or practice settings (NICU, well-newborn nursery, or both) (P > .05).

CONCLUSIONS

Our study findings suggest that newborn clinicians may lack knowledge about the effectiveness of oral vitamin K in preventing VKDB. More information is needed about oral vitamin K regimens and outcomes of newborns who receive oral vitamin K.

Refusal of Vitamin K by Parents of Newborns: A Qualitative Study

OBJECTIVE

Despite American Academy of Pediatrics recommendations, some parents refuse intramuscular (IM) vitamin K as prophylaxis against vitamin K deficiency bleeding for their newborns. The purpose of our study was to describe attitudes and perceptions of parents who choose to defer IM vitamin K for their newborns.

METHODS

Using qualitative methodology, we conducted in-depth semi-structured interviews with parents of newborns in 3 hospitals in Connecticut and California. We used the grounded theory approach and the constant comparative method until saturation was reached.

RESULTS

Nineteen participants (17 mothers and 2 fathers) of 17 newborns were interviewed; 14 newborns did not receive IM vitamin K due to refusal by the parents, and for 3 newborns IM vitamin K administration was delayed due to initial hesitation by the parents. Four major themes emerged: 1) risk-to-benefit ratio, where parents refused IM vitamin K due to a perceived risk to their newborn from preservatives, for example; 2) "natural" approaches, which led to seeking oral vitamin K or increasing the mother's own prenatal dietary vitamin K intake; 3) placement of trust and mistrust, which involved mistrust of the medical and pharmaceutical community with overlapping concerns about vaccines and trust of self, like-minded allopathic and non-allopathic health care providers, the social circle, the internet, and social media; and 4) informed by experiences, reflecting hospital experiences with prior pregnancies and communication with health care providers.

CONCLUSIONS

Parents' perception of risk, preference for alternative options, trust, and communication with health care providers were pivotal factors when making decisions about IM vitamin K.

Parental Refusal of Standard-of-Care Prophylactic Newborn Practices: In One Center's Experience, Many Refuse One but Few Refuse All

OBJECTIVES

Several interventions to reduce neonatal morbidity and mortality are universally recommended: intramuscular (IM) vitamin K (VK), erythromycin ophthalmic prophylaxis, and hepatitis B vaccine for newborns, and maternal pertussis vaccine. Despite robust efficacy and safety evidence, parental refusal of these practices is increasing. We sought to define the current declination rate and characterize the association between declination of 1 intervention and declination of the others.

METHODS

A retrospective cohort study was performed of all inborn singletons admitted to the well newborn nursery over a 12-month period (November 15, 2015 through November 15, 2016) at a large quaternary center.

RESULTS

In total, 3758 infants met inclusion criteria. 25% (n = 921) did not receive at least 1 of the 4 interventions. 13.6% (n = 511) did not receive the hepatitis B vaccine, 2.3% (n = 85) did not receive IM VK, 5.9% (n = 223) did not receive erythromycin, and 7.2% (n = 271) of mothers did not receive the prenatal tetanus, diphtheria, pertussis vaccine. Odds of refusal of IM VK were 6.2 times greater for infants delivered by a certified nurse midwife versus physician (95% confidence interval 3.3-11.6). Pattern of declination was variable; of 921 mother-infant dyads who did not receive at least 1 intervention, only 2 dyads received none of the interventions.

CONCLUSIONS

Our study is one of the first in which patterns of refusal of standard-of-care perinatal practices are characterized. Alarmingly, one-fourth of our cohort did not receive at least 1 core infant health intervention. Our finding of only modest overlap in declination of each intervention carries implications for the development of targeted interventions.