Vitamin K Injection and the Newborn

Vitamin K….

So I have been requested to do a blog on Vitamin K injection and the newborn. And here I sit…facing the same ‘problem’ I face every time I try to write an educational blog post: the information has already been written, they won’t learn anything from me that they can’t learn elsewhere, there’s so much information how can I condense it all into a reasonable sized blog post.

So I am just going to hit some of the major points and then direct you to more information at the end…

What is Vitamin K? It is a fat-soluble substance that triggers the blood clotting process. It is offered to every single newborn baby born in the US – specifically for the preventative/treatment of a very rare condition called “newborn hemorrhagic disease” – or, more recently they have changed the terminology to “Vitamin K deficiency bleeding (VKDB)”.
How rare? College of Midwives of Manitoba state the occurrence as…

  • Early VKDB (first week of life): 0.4 to 1.7 %
  • Disabling or fatal hemorrhage: 2.2 per 100 000 births
  • Late VKDB (weeks 2-12 of life): 4.4 to 10.5 per 100 000 births

Rare? You bet…especially when you consider that there are several factors that increase your baby’s risk of having this condition – they include

  • hepatitis
  • cystic fibrosis
  • chronic diarrhoea
  • bile duct atresia
  • alpha-1-antitrypsin deficiency
  • celiac disease of insufficient plasma transport capacity

It is also associated with babies whose mothers took anticonvulsant, antituberculous or anticoagulant drugs while she was pregnant. Newborns who are premature, or who have had a traumatic birth (such as forceps or vacuum extraction) are also at an increased risk of bleeding.

So you have a baby that does not have one of the above listed conditions, and you are a mother who has not taken the above listed medications….then obviously the risk of your baby having VKDB is notably LOWER than the already low rates listed above.

What if we don’t give it? The fear is that if we don’t give your baby Vit K, then s/he could have that rare VKDB condition and bleed (especially into the brain) and cause brain damage or death.
NOTE: All babies are born with lower levels of Vitamin K…so how can we call them “deficient”?

A baby’s natural Vitamin K production (since a lot of it is synthesized in the baby’s gut) doesn’t really kick in until the 8th day of life. Even then, breastfed babies almost consistently have lower levels of Vitamin K than formula fed babies as formula has such high levels of Vitamin K added to them.
ANOTHER NOTE: If you are having a boy AND you plan to circumcise your baby AND you are having a pediatrician perform the circumcision – I do not know a pediatrician in my state who will agree to perform it if the baby has not received a Vitamin K shot. A Jewish Mohel performs circumcisions on the 8th day of life according to Jewish law – coincidence that this is when the baby’s own production of Vitamin K kicks up?

What if we choose to give it? Then you have another consideration that most people don’t know about or realize – do you want to give it via injection (routine/standard) or orally? Studies have shown both delivery methods to be equally effective! Why then inject the baby? Quick, easy, don’t have to worry about baby spitting it out…?

So lets say you birth your baby in a hospital and you want your baby given Vitamin K but don’t want an injection. You mention this to the staff and they say that they don’t HAVE oral Vitamin K anywhere in the hospital, only the injectable. The injectable Vitamin K is the same as the oral – all they need to do is draw it up in the syringe, take off the needle, and squirt it into the baby’s cheek. Oral dosages tend to ‘wear off’ faster than their injectable counterparts, so it’s recommended that it be repeated later as well.

NOTE: Studies show that a mother’s diet/supplementation of Vit K prior to the birth of her baby DOES NOT effect Vitamin K levels in her newborn – suggesting that the levels in the baby are highly specific and highly regulated by the baby.

Are there risks to the Vitamin K? Here is where the true debate lies. To quote vaclib.org, “There has been some debate over the years as to whether or not HDN is actually caused by vitamin K deficiency. Certainly, giving vitamin K does arrest bleeding in the majority of cases, but this does not mean that vitamin K deficiency causes HDN. One may as well say that an antibiotic deficiency causes bacterial infection.”
There have been studies that show a NOTABLE link between Vit K and Leukemia (Vitamin K has been shown to be involved in regulating the rate of cell division in the fetus. It’s possible that abnormally high levels of vitamin K can allow cell division to get out of hand, leading to cancer) – but then there have been follow up studies that show no correlation. A question commonly asked is…if all babies are born with low Vit K levels, then isn’t there probably a REASON, whether we know it or not?

Conclusion- I’m going to make my job easy and simply point you to websites with SCADS of references and information. Below you will find some good well-researched information that should answer any questions I was unable to here.

The good news is that there’s not a huge risk either way – the bad news is that it’s not a black/white issue and so you will have to make that decision for yourself. I will fulfill my legal obligation and offer the injection to every baby I am the midwife for, but I have no problem whatsoever if a client chooses to refuse it (and, in fact, the vast majority of my clients do as the vast majority have relatively gentle births and the vast majority of them do not circumcise)

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If you would like further information than the VERY short/limited information I have provided, please visit the websites listed below. They offer EXCELLENT food for thought and are very well sourced!

http://www.nichd.nih.gov/cochrane/puckett/review.htm – this is a GREAT source of information on some of the larger studies that have been done. Scan down about ¾ of the way and you will see the studies layed out neatly in table form for you.

http://www.vaclib.org/basic/vitamin-k.htm – thought provoking, well-done….83 different studies and papers referenced (so you see why it’s a daunting task for ME and why I prefer to simply point you to them!) I thought that this was an excellent read!!

17 Comments

  1. Maren Meacham wrote:

    The fact that you make this short and sweet is a so much easier to get the info. You inform people with out confusing them and really let them choose. I love and appreciate that about you more than you know.

    Friday, August 13, 2010 at 10:55 am | Permalink
  2. GREAT breakdown! Thanks for the short and sweet version. I learned a lot!

    Friday, August 13, 2010 at 10:57 am | Permalink
  3. In my experience, there *are* times when a Vitamin K injection might be/is warranted. If the baby has had a traumatic birth (shoulder dystocia, forceps, vacuum “extraction,” some breeches, etc.) or if the baby is born with a bruise because of a compound presentation or a birth injury (but be careful not to think a Mongolian spot is a bruise!). The reason I give it in injection in these situations (with consent, of course) is it gets into the system faster than if you did the multiple oral doses.

    I’ve read through the leukemia accusation studies and find them irrelevant to the topic; if Vit K caused leukemia, there’d be a WHOLE lot more leukemia in our country than there is. But, you are right, everyone gets to make their own decisions.

    I did not know you could use the injectable as oral dose, so that’s new to me. Thanks! And, from what I know, it needs to be repeated 3 times, 12 hours apart. Is that your experience, too?

    Thank you very much for the piece… you write so beautifully and did a great job. Thank you!

    Friday, August 13, 2010 at 11:09 am | Permalink
  4. elfanie wrote:

    Barbara (Navelgazing midwife for those not “in the know” – heh)

    There was a review of studies on the first link (at the end of the article) which compared a single injection to single oral dose to serial doses of Vit K….where the conclusion was (and I quote as it is sourced and linked above), “A single oral compared with a single intramuscular dose resulted in lower plasma vitamin K levels at two weeks and one month, whereas a 3-dose oral schedule resulted in higher plasma vitamin K levels at two weeks and at two months than did a single intramuscular dose. ”

    so…from MY research it would appear that giving a single 1mg oral dose is the closest ‘equal’ in this situation to giving a single 1mg injection (since the Vit K levels were notably higher with one oral dose vs. placebo) – however, the 3-dose regime would increase levels even higher.

    HOWEVER (and this is a big big ‘however”)…my investigation showed that the 3-dose level performed in studies was “the first given at the first feeding, the second at 2 to 4 weeks and the third at 8 weeks”
    I could not find in studies serial oral dosages that close together and the concern I would have is…understanding the fact that the effect is much LONGER than just a few hours in the babies bodies (as evidence by vit K levels a week+ after the single dosage), serial dosages within that time frame would increase the levels in baby even more – is there a risk to that? benefit? we don’t know…but it would be notably higher than the single injection that is standard right now….

    Friday, August 13, 2010 at 11:26 am | Permalink
  5. Sharon wrote:

    So those rates are based on incidence in populations that receive supplemental vitamin K. The rates of vkdb early middle or late in populations of exclusively breastfed infants that do not receive supplemental feeds or vitamin k orally or injectible is somewhere around 1-2 per 1000.
    This is what was reported by Mcninch in England in the 80s, the health department retrospective in NY that caused the state to require vit K for all no waivers, and what is currently reported in Bejing China and Thailand. the studies in Thailand went into looking at risk factors and maternal diet that is below the US RDA. 90 micrograms / day were at higher risk – the lower the maternal intake the higher the risk– 50 micrograms a day and less have the greatest risk- nutritional studies show that the average daily intake for woe of childbearing age is 50 micrograms a day.So average diet here will put our infants at the risk.

    Friday, August 13, 2010 at 12:22 pm | Permalink
  6. Guggie wrote:

    I do wish parents were aware of the difference between taking the syringe contents orally versus purchasing an oral supplement.

    Depending on their area, the syringe version contains several preservatives, and I think one version still contains mercury.

    I wouldn’t want my infant to receive that orally or parenterally.

    Friday, August 13, 2010 at 12:44 pm | Permalink
  7. erinmidwife wrote:

    In my experience midwives often like to downplay the incidence of VKDB because they are opposed to vitamin K prophylaxis. However a number of midwife friends of mine, myself included, have had babies affected by VKDB. (I have seen 2 in 5 years). The incidence of late VKDB is higher in exclusively breastfed babies.

    The risk of early VKDB comes almost entirely from meds the mother is taken. The same is not true for the classic and late forms, which do have a different etiology.

    It is really almost impossible to know the true incidence of VKDB in our population because nearly every baby receives vitamin K prophylaxis. Yes we have studies looking at numbers from other countries and ethnicities, but whether those an be extrapolated to North American babies is debatable.

    Friday, August 13, 2010 at 4:48 pm | Permalink
  8. elfanie wrote:

    Erin…
    Whether I have seen VKDB or not is irrelevant….it doesn’t change the studies or reported incident. I might change the perception of whether it is “rare” or not…but it doesn’t change the rate – only changes our perception of it. I try and report facts….which is where the numbers came from. If you have studies that show that VKDB has a higher occurrence then I think that would be important to share as well….and would appreciate it if you would post it here! My intent is not to skew or persuade…but simply educate.

    I am curious, however, if maternal diet during pregnancy does not effect the levels in the newborn – then why do you believe that it is questionable whether we should look at the numbers from other countries and ethnicities? (since the “maternal diet” variable is apparently removed – and since the US has a variety of ethnicities..)

    Friday, August 13, 2010 at 5:30 pm | Permalink
  9. Amy wrote:

    As usual, your blog helped me narrow down a ton of information out there in “internet land” into something useful! You are such an experienced source and that means a lot. Thanks for being willing to write about this subject. One other subject I’m currently wrestling with is cord blood banking. I want to do it for my 3rd as I did with my other two, but I am concerned with “clamping/cutting” too soon. Would love your thoughts in another blog at some point on this. I’ve seen so much info on the benefits of delaying, but have seen nothing clear cut on how long you can actually wait and still get cord blood or if it’s something you even recommend doing at all.

    Friday, August 13, 2010 at 8:32 pm | Permalink
  10. Sharon wrote:

    How the reported incidence is looked at does change.
    In the one nicely written but biased paper Stephanine linked to the writer actually quotes McNinch using his introductory statement about 1/2 the newborn population getting supplemental K. What isn’t quoted from that article is it is a case report of an shocking increase in babies with vkdb the raw rate being stated as 1 out of 1200, but he also states at the time they were treating for risk factors. But if you look further he and others are really trying to figure out what happened, he says what else changed in that time period is a move from supplemental bottle feeds to exclusive breastfeeding. In later papers he explores the possibility that environmental toxins may play a role -so if you strip away the babies who were given vitamin k the incidence is greater than 1/1200. Even in the recent reports the incidence is never measured out of babies who do not receive vitamin k but our of the total population, they also only record for national standards the confirmed cases so in the most recent reports with 80% of the districts reporting they had 46 suspected cases but they had only confirmed 11 casaes, the majority of the incidence being in babies who were exclusively breasted and did not get vitamin k or only got one dose of oral- not the babies with metabolic disorders that are failures of oral dosing, but just plain old ordinary babies – and the reported rate is stated as incidence out of total population. The rate of incidence if boiled down to how often it occurs in thie non- supplementing population.
    So I mentioned the other countries before and the NY retrospective , the thing is that the rates are all similar regardless of year or country. Places like China and Thailand at this point still have those populations as majority.
    Another touch point I would make is that Shearer authored the study in the early 90′s saying that maternal diet is meaningless, but he is one of the authors of the current study in Thailand that shows maternal diet in pregnancy and breastfeeding makes a difference- so I would guess he is reversing himself on that info.
    In talking with midwives as well as personal experience , the numbers of close calls- where the mw administers vitamin K because of symptoms days or weeks after the birth, or the frankly seriously Ill infants that mw’s have had leads me to believe that the 2/ 1000 is probably pretty close.

    Friday, August 13, 2010 at 8:57 pm | Permalink
  11. Krista wrote:

    What I would like to know as a consumer, is has there been any pondering of the fact that once you give Oral Vit K to a newborn, the pristine gut has been altered by introducing something other than breastmilk. Especially for Vit K given multiple doses. Would the risk/benefit then not be in favour of the injectable dose, given what we are only now beginning to fully understand about the harm that anything oral other than breastmilk can potentially cause to optimal internal flora?

    Friday, August 13, 2010 at 11:44 pm | Permalink
  12. Sharon wrote:

    The injectable exits the body primarily via the intestines.
    Intestinal flora manipulates leftover vitamin K1 from food or in an infant’s diet breastmilk and converts it to K2 ( mk4) if breast milk has abnormally low levels or forms that are poorly digested by flora like dihydrophylloquinone,(typeof K1 formed by hydrogenated oil) then the flora is being altered by that too. recent studies on dihydro show that there is very little K2 produced when people consume hydrogenated oils, so the flora are either not able to digest it or our bodies do not absorb and utilize the K2 formed from it.
    The bulk of the research on vitamin k in the past 10 years has little to do with neonatal use and more to do with vitamin K as it relates to the aging process. So the lack of secondary properties of dihydro K is implicated in all sorts of problems from increased inflammatory markers to aging damage to myelin sheaths from lack of K2.
    Recommending altered maternal diets to reflect the life long importance of healthy vitamin K foods is probably a bigger goal than the insurance measures of newborn supplementation,but that is much easier said than done.

    Saturday, August 14, 2010 at 2:57 am | Permalink
  13. Here is my theory (and it is only a theory):
    “Think about It
    The powers that be recommend active management of third stage (cord cutting and placental delivery) where Pitocin is given, the cord is clamped and cut immediately (within two minutes of birth), and the placenta is delivered immediately. This is done out of fear of polycythemia, jaundice and hemorrhage.
    Babies also are commonly given a prophylactic shot of vitamin K after birth to prevent hemorrhagic disease, because they have naturally low levels of vitamin K after birth. (Note: Vitamin K is produced in the gut once the baby has received adequate breast milk.)
    Polycythemia is essentially an excess of red blood cells (RBCs). High numbers of red cells increase the blood’s viscosity. Blood flow to organs is reduced and, in rare cases, blood clots can form.
    So, what if the whole reason that babies are low in vitamin K, is because polycythemia is normal after birth? In other words, perhaps the human system was designed so vitamin K should be low naturally to counteract the excessive RBCs. Are we creating new problems by altering the normal physiological balance of the mother/baby disconnection?
    Perhaps the reason active management works, to a certain extent, is that prophylactic vitamin K is given. So if we have a natural physiological third stage, would we then be creating additional problems by giving vitamin K? OR should we develop new rules that say if you are doing active management of third stage—yes, you need vitamin K; conversely, if you are practicing a natural third stage then there is no need for additional vitamin K? Amy V. Haas, BCCE

    Saturday, August 14, 2010 at 3:41 pm | Permalink
  14. Sharon wrote:

    I have been gathering info on this topic in the past few days re-putting together a presentation so it is fresh on my mind. Infants do not get an intestinal vitamin K factory, especially if the baby is born vaginally at term, and is exclusively breastfed , born vaginally and is not exposed to antibiotics- the flora consists is rich in Bifidobacterium, obligate anaerobes, some rare sprinklings of Clostridium and Bacteroides , enterobacteria and enterococci are relatively few. These critters just don’t put out that much K2, unlike bottle fed infants who’s primary bacteria is entero and ecoli and some other critters and there is a greater sprinkinglin of bifidus bacteria if the babies are born vaginally and not hospitalized for any problems that flora does ferment more and produces K2 but there is still a question of the liver managing the proteins and it looks as though mom’s body does the providing of K2 if she has enough K1 as raw materials for her body to convert so it will be present in her milk .
    to think about delayed cord clamping in this context, I do not know any mws who do not wait for the cord to stop pulsing , but I do know of over 15 cases of vkdb and even more “near” misses. If the stat of 4/1000000 were true given the numbers of home births in the country how many should I know about? 4 or less… the Netherlands has a special committee that pays attention to such things and that is how they know about and fine tune oral vitamin K dosages.In the UK they have special focus info gathering that specifically collects data/reports of vitamin K deficiency bleeds- and we are trying to extrapolate from their info what might be true for out populations- in the 1960′s the stated rates of babies with prolonged prothombin times who were breast fed and did not get supplemental vitamin K was 1 in 150.

    Saturday, August 14, 2010 at 9:24 pm | Permalink
  15. Laura wrote:

    Re circumcision, in Nigeria little girls are circumcised on the 8th day too. It’s not ok to take a razor to a baby’s most delicate sensitive bits, whatever the gender! A study by British Mohelim who were also doctors found 2-3% of babies needed follow up treatment for haemorrhage….They were all sliced on their 8th day in the world!

    Genital reduction surgery on a newborn is never a safe act, and doing it because of tradition or hatred of the parts is NEVER morally acceptable.

    Sunday, August 15, 2010 at 4:18 am | Permalink
  16. alli wrote:

    i am so glad you posted this! i live in mesa and my first is due next month, a boy, and we are planning to circumcise. i called the dr. who is to perform the task to find out when the shot should be given. since we are having a homebirth, and wouldnt be automatically given, did it need to be done the day of birth, or could it wait until the day of circumcision? i found out from the receptionist that the dr. no longer requires the vit k shot! the baby just has to be brought in after he’s a week old, but before he’s a month old. the dr is dr. dobrusin. his practice is near stapley& mckellips. i later confirmed this with my midwife who spoke with the dr. directly.

    Sunday, August 15, 2010 at 9:19 am | Permalink
  17. Christy wrote:

    Dr. Dobrusin (a family practice doc & Jewish mohel) in Mesa did my sons circumcision in his office without him having had the Vit K shot. FYI if you ever need the resource.

    Sunday, February 20, 2011 at 8:11 pm | Permalink

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