Neonatal vitamin K prophylaxis in Great Britain and Ireland: the impact of perceived risk and product licensing on effectiveness

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.

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.

A Practical Guide to the Management of the Fetus and Newborn With Hemophilia

Newborns with hemophilia are at risk of intracranial hemorrhage, extracranial hemorrhage, and other bleeding complications. The safe delivery of a healthy newborn with hemophilia is a complex process that can begin even before conception, and continues throughout pregnancy, birth, and the newborn period. This process involves the expectant parents and a wide variety of health-care professionals: genetic counselors, obstetricians, neonatologists, pediatricians, radiologists, adult and pediatric hematologists, and nurses with expertise in hemophilia. Because of this multidisciplinary complexity, the relative rarity of births of newborns with hemophilia, and the lack of high-quality evidence to inform decisions, there is considerable variation in practice in this area. We present a comprehensive multidisciplinary approach, from preconception counseling to discharge planning after birth, and describe available options for management decisions. We highlight a number of areas of important uncertainty and controversy, including the preferred mode of delivery, the appropriate use and timing of neuroimaging tests, and the appropriate use of clotting factor concentrates in the newborn period. While the approach presented here will aid clinicians in planning and providing care, further research is required to optimize the care of newborns with hemophilia.

Dietary reference values for vitamin K

Following a request from the European Commission, the EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA) derives dietary reference values (DRVs) for vitamin K. In this Opinion, the Panel considers vitamin K to comprise both phylloquinone and menaquinones. The Panel considers that none of the biomarkers of vitamin K intake or status is suitable by itself to derive DRVs for vitamin K. Several health outcomes possibly associated with vitamin K intake were also considered but data could not be used to establish DRVs. The Panel considers that average requirements and population reference intakes for vitamin K cannot be derived for adults, infants and children, and therefore sets adequate intakes (AIs). The Panel considers that available evidence on occurrence, absorption, function and content in the body or organs of menaquinones is insufficient, and, therefore, sets AIs for phylloquinone only. Having assessed additional evidence available since 1993 in particular related to biomarkers, intake data and the factorial approach, which all are associated with considerable uncertainties, the Panel maintains the reference value proposed by the Scientific Committee for Food (SCF) in 1993. An AI of 1 μg phylloquinone/kg body weight per day is set for all age and sex population groups. Considering the respective reference body weights, AIs for phylloquinone are set at 70 μg/day for all adults including pregnant and lactating women, at 10 μg/day for infants aged 7-11 months, and between 12 μg/day for children aged 1-3 years and 65 μg/day for children aged 15-17 years.

Vitamin K supplementation to prevent hemorrhagic morbidity and mortality of newborns in India and China

BACKGROUND

Vitamin K deficiency bleeding (VKDB) can cause prolonged and bleeding (intracranial hemorrhage) among newborns, which can be life-threatening or lead to long-term morbidity. The aim of this review article is to reiterate empirical evidence to support the argument that vitamin K should be mandatory for newborns in India and China, as well as in other countries with a high burden of neonatal deaths.

DATA SOURCES

Studies were integrated from the PubMed/MEDLINE database search, as well as related literature available elsewhere.

RESULTS

Both India and China have been slow in adopting an effective program for administering vitamin K injections to newborns to prevent VKDB-related morbidity and mortality. VKDB cases in China and India have shown inadequate attention to routine use of vitamin K by injection.

CONCLUSIONS

While no reliable data are publicly available, the issue of VKDB is at last receiving some attention from the Chinese public health system as well as the Indian government. In both countries, routine vitamin K administration to newborns would prove to be a cost-effective intervention to reduce preventable neonatal morbidity and mortality. VKDB is a global neonatal care issue, including countries where parental resistance is preventing babies from defense against this life-threatening condition.

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.

Rise in late onset vitamin K deficiency bleeding in young infants because of omission or refusal of prophylaxis at birth

BACKGROUND

Newborns are at risk for vitamin K deficiency and subsequent bleeding unless supplemented at birth. Vitamin K deficiency bleeding is an acquired coagulopathy in newborn infants because of accumulation of inactive vitamin K-dependent coagulation factors, which leads to an increased bleeding tendency. Supplementation of vitamin K at birth has been recommended in the United States since 1961 and successfully reduced the risk of major bleeding. Refusal or omission of vitamin K prophylaxis is increasing and puts newborn infants at risk for life-threatening bleeding.

PATIENTS

Over an eight month period, we encountered seven infants with confirmed vitamin K deficiency; five of these patients developed vitamin K deficiency bleeding.

RESULTS

The mean age of the seven infants with vitamin K deficiency was 10.3 weeks (range, 7-20 weeks); manifestations ranged from overt bleeding to vomiting, poor feeding, and lethargy. None of the infants had received vitamin K at birth, and all were found to have profound derangement of coagulation parameters, which corrected rapidly with administration of vitamin K in IV or intramuscular form. Four of the seven infants had intracranial hemorrhage; two of these infants required urgent neurosurgical intervention.

CONCLUSION

Supplementation of vitamin K at birth for all newborns prevents major hemorrhagic complications, such as intracranial bleeding, due to vitamin K deficiency. Parental refusal of vitamin K is increasingly common. It is critical that health care providers and the public be made aware of the varied presentation of this preventable acquired coagulopathy.

Parents' knowledge and perceptions regarding vitamin K prophylaxis in newborns

BACKGROUND

There is an increasing trend of parents refusing vitamin K (VK) prophylaxis in newborns. We examined the knowledge, perceptions, cultural and religious barriers of expecting parents regarding VK prophylaxis.

OBSERVATIONS

Questionnaires were completed by 217 participants: 151 female participants and 85% were expecting their first child. Two thirds had academic degrees, yet were ignorant regarding recommendation to provide VK (22.5%), source (15.5%), action (34%), and provision options (29%). Moreover, first-time parents had not yet decided to provide VK after birth (P<0.05).

CONCLUSIONS

There is a need to provide expecting parents with information regarding safety, utility, and benefits of VK prophylaxis.

Vitamin K nutrition, metabolism, and requirements: current concepts and future research

In 2001, the US Food and Nutrition Board concluded that there were insufficient data with which to establish a RDA for vitamin K, in large part because of a lack of robust endpoints that reflected adequacy of intake. Knowledge of the relative bioavailability of multiple vitamin K forms was also poor. Since then, stable isotope methodologies have been applied to the assessment of the bioavailability of the major dietary form of vitamin K in its free state and when incorporated into a plant matrix. There is a need for stable isotope studies with enhanced sensitivity to expand knowledge of the bioavailability, absorption, disposition, and metabolism of different molecular forms of vitamin K. Another area for future research stems from evidence that common polymorphisms or haplotypes in certain key genes implicated in vitamin K metabolism might affect nutritional requirements. Thus far, much of this evidence is indirect via effects on warfarin dose requirements. In terms of clinical endpoints, vitamin K deficiency in early infancy continues to be a leading cause of intracranial bleeding even in developed countries and the reasons for its higher prevalence in certain Asian countries has not been solved. There is universal consensus for the need for vitamin K prophylaxis in newborns, but the effectiveness of any vitamin K prophylactic regimen needs to be based on sound nutritional principles. In contrast, there is still a lack of suitable biomarkers or clinical endpoints that can be used to determine vitamin K requirements among adults.

Vitamin K prophylaxis and late vitamin K deficiency bleeding in infants: fifth nationwide survey in Japan

BACKGROUND

In 1980, the first nationwide survey on late vitamin K deficiency bleeding (VKDB) in infants was conducted in Japan, and it was followed by the second, third and fourth nationwide surveys in 1985, 1988 and 1991, respectively. The fifth nationwide survey was designed to ascertain the epidemiology of late VKDB between January 1999 and December 2004.

PATIENTS AND METHODS

Questionnaires were sent to 2161 hospitals in Japan that employed members of the Japan Pediatric Society in March 2005. Responses were received from 1373 hospitals, for a response rate of 63.5%.

RESULTS

The total number of reported cases was 71, including 21 idiopathic type and 16 secondary type. The incidence of late VKDB was estimated to be 1.9 cases per 100,000 births (95% confidence interval: 1.2-3.0) during this survey period. In 34 cases, the presence or absence of any underlying disease was not clarified. A total of 67/71 infants were entirely breast-fed. Intracranial hemorrhaging was observed in 26 (63.4%) out of 41 infants whose bleeding sites were described in the questionnaires. In 63 cases (88.7%) of late VKDB found in the present survey, however, vitamin K had been given at least once either during or after the neonatal period.

CONCLUSIONS

A reevaluation of the current prophylaxis strategy for late VKDB in infants is necessary.

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

AIM

To undertake surveillance of vitamin K deficiency bleeding (VKDB) from 1998, through the transition to a new single licensed vitamin K preparation in 2001, to 2008.

METHODS

VKDB was listed with other rare conditions on the card sent monthly to registered specialist paediatricians by the New Zealand Paediatric Surveillance Unit with a request to indicate whether or not a case had been seen in the previous month. Those notifying a case were sent a two-page questionnaire. The main outcome measures were incidence of VKDB of early (first day of life), classic (days 2-7) and late-onset (day 8 to 6 months) type; related morbidity and mortality; receipt of vitamin K; and predisposing factors.

RESULTS

Response rate of return of surveillance cards was high, averaging 94.5%. There were 35 notifications of which 23 were valid cases. Seventeen cases met criteria for confirmed VKDB, two for 'probable' and four for 'possible'. There were eight confirmed classic cases with an overall incidence of 1.24 (95% confidence interval 0.54-2.45) per 100,000 births; none had received vitamin K prophylaxis, seven were fully breastfed and all fully recovered. There were nine confirmed late-onset cases with an overall incidence of 1.40 (95% confidence interval 0.64-2.65) per 100,000 births; eight had received no vitamin K, eight were fully breastfed, six had liver disease, four suffered an intracranial haemorrhage and one died.

CONCLUSIONS

In New Zealand, VKDB is virtually confined to fully breastfed infants not given vitamin K at birth. Late-onset cases were frequently associated with liver disease.

[Prophylactic vitamin K for vitamin K deficiency bleeding of the newborn]

BACKGROUND

The administration of vitamin K immediately after birth has shown a significant decrease in the incidence of newborn bleeding, but there is not enough evidence to determine the most appropriate method of administration. The objective of this review is to determine the effectiveness of orally administered vitamin K compared to the intramuscular route in the prevention of hemorrhagic disease of newborn (HDN).

METHODS

We conducted a systematic review of the main databases (Medline, Embase and Cochrane, among others) without limitation by date, language or type of study. Selected studies evaluated the efficacy and safety of vitamin K. Excluded were studies in pregnant women in preterm infants or patients with pathology. The validity of these studies was assessed by CASPe tools for systematic reviews and clinical trials.

RESULTS

Only two studies evaluated clinical aspects. They showed a reduction in the incidence of bleeding in the newborn after intramuscular prophylaxis with vitamin K. With regard to the oral route, different studies examined the effectiveness of vitamin K by determining biochemical parameters (factor X, prothrombin time and index, vitamin K1 in plasma and prothrombin antigen, among others) with inconclusive results regarding the route of administration and the number of doses.

CONCLUSIONS

There is sufficient evidence to support the effectiveness of a single intramuscular dose of vitamin K to prevent the classic form of HDN. With regard to late HDN and oral route, the results are inconclusive because the studies used biochemical indicators of effectiveness, which can not be correlated with the actual coagulation status of the newborn due to lack of scientific evidence.

Vitamin K deficiency bleeding: early history and recent trends in the United Kingdom

At the start of the 20th century the mechanisms of haemostasis were virtually unknown. Townsend had coined the term 'Haemorrhagic disease of the newborn' in 1894 but it was not until the discovery of vitamin K ('Koagulation vitamin') by Dam and others in the 1930s that the condition became understood, allowing treatment and prophylaxis. Methods of prophylaxis (preparations used, doses and routes of administration), still widely debated, have varied with time and from one country to another. The formation of the British Paediatric Surveillance Unit in the 1980s has allowed a series of prospective population studies of Vitamin K deficiency bleeding (VKDB) in the United Kingdom (UK) and Ireland which, together with contemporaneous surveys of practices of vitamin K prophylaxis, have greatly improved our understanding of the condition and informed practices of prophylaxis. In the UK prophylaxis (by injection or by mouth) is now offered to every newborn baby and VKDB is very rare, most cases occurring in breastfed babies whose parents have refused prophylaxis; by contrast, in developing countries most babies do not receive prophylaxis and VKDB is probably a common (but poorly documented) cause of death and handicap in the early months of life. Vitamin K prophylaxis should be available to all newborn babies.

Evaluation of the acceptability of a new oral vitamin K prophylaxis for breastfed infants

AIM

The aim of this study was to investigate the acceptability and tolerability of the oral food supplement Neokay for the prevention of vitamin K deficiency bleeding in newborns.

METHODS

A questionnaire survey was conducted among 45 midwives in which they were asked 10 questions about their use of Neokay, its advantages and disadvantages, and their perceptions of parental attitudes towards this new prophylactic treatment.

RESULTS

During a 6-month period one dose of Neokay was given to 1794 healthy newborns at birth and further daily doses were given to 812 breastfed infants for 3 months. The midwives listed as main advantages ease of administration, no need for prescription or written consent, and transfer of responsibility to parents. As disadvantages, they mentioned possible reduced compliance as a result of the frequency of dosing, decreased parental confidence in breastfeeding and technical issues with packaging.

CONCLUSION

A prophylactic vitamin K dosage regimen of 1 mg oral vitamin K (Konakion MM Paediatric or Orakay) given to all healthy neonates at birth, combined with daily doses of 50 microg Neokay for 3 months for breastfed babies is well tolerated and acceptable to midwives and parents.

Vitamin K, an update for the paediatrician

INTRODUCTION

This review summarizes current knowledge on vitamin K for the paediatrician. Vitamin K is a fat-soluble vitamin, present in plants as phylloquinone and produced by bacteria as menaquinone. It is acting as a co-factor for gamma-glutamyl carboxylase. This enzyme is responsible for post-translational modification of some glutamate side chains to gamma-carboxyglutamate. The majority of gamma-carboxylated proteins function in blood coagulation; others play a role in calcium homeostasis.

DATA

Newborn babies are at particular risk of vitamin K deficiency, as placental transfer is limited and human milk is a poor source. Vitamin K prophylaxis at birth effectively prevents vitamin K deficiency bleeding (VKDB), formerly known as "haemorrhagic disease of the newborn". Recent epidemiological studies provide data on the effectiveness of different administration routes and dosing schemes. Infants of mothers taking drugs that inhibit vitamin K are at risk of early VKDB and should receive 1 mg intramuscular (i.m.) as soon as possible after birth. Classic VKDB is prevented by intramuscular as well as by oral administration of 1 mg vitamin K. In exclusively breast-fed infants, single i.m. administration at birth is also effectively preventing (rare) late VKDB but single oral administration is not. If given orally, prophylaxis should be continued by either weekly administration of 1 mg till 12 weeks or repeating 2 mg at weeks 1 and 4. Daily administration of 25 microg offers insufficient protection. The only infants not fully protected in this way are those with yet unrecognised liver disease.

CONCLUSIONS

Further work is needed before firm recommendations can be made regarding dose in preterm infants and in patients with fat malabsorption/cholestasis or regarding the role of vitamin K in the prevention of osteoporosis.

Vitamin K deficiency bleeding (VKDB) in early infancy

Vitamin K deficiency bleeding (VKDB) is a rare and potentially life-threatening bleeding disorder of early infancy. Vitamin K stores are low at birth; thereafter breast-fed infants are at risk because of low concentrations in human milk. Classical VKDB occurs in the first week of life, is related to delayed or inadequate feeding and is readily prevented by small doses of vitamin K at birth. Late VKDB peaks at 3-8 weeks, typically presents with intracranial haemorrhage often due to undiagnosed cholestasis with resultant malabsorption of vitamin K. Diagnosis can be difficult but PIVKA-II measurements can provide confirmation even several days post-treatment. Without vitamin K prophylaxis, the incidence of late VKDB in Europe is 4-7 cases per 10(5) births; it is higher in SE Asia where in rural, low-income areas some 0.1% of affected infants may suffer intracranial bleeding. Late VKDB is largely preventable with parenteral vitamin K providing the best protection. The efficacy of oral prophylaxis is related to the dose and frequency of administration. Most multi-dose oral regimens provide protection for all except a small reservoir of infants with undetected hepatobiliary disease. Targeted surveillance of high-risk groups (e.g. biliary atresia) offers a novel approach to assess efficacy of prophylaxis.

Prevention of vitamin K deficiency bleeding in breastfed infants: lessons from the Dutch and Danish biliary atresia registries

OBJECTIVE

Newborns routinely receive vitamin K to prevent vitamin K deficiency bleeding. The efficacy of oral vitamin K administration may be compromised in infants with unrecognized cholestasis. We aimed to compare the risk of vitamin K deficiency bleeding under different prophylactic regimens in infants with biliary atresia.

PATIENTS AND METHODS

From Dutch and Danish national biliary atresia registries, we retrieved infants who were either breastfed and received 1 mg of oral vitamin K at birth followed by 25 microg of daily oral vitamin K prophylaxis (Netherlands, 1991-2003), 2 mg of oral vitamin K at birth followed by 1 mg of weekly oral prophylaxis (Denmark, 1994 to May 2000), or 2 mg of intramuscular prophylaxis at birth (Denmark, June 2000-2005) or were fed by formula. We determined the absolute and relative risk of severe vitamin K deficiency and vitamin K deficiency bleeding on diagnosis in breastfed infants on each prophylactic regimen and in formula-fed infants.

RESULTS

Vitamin K deficiency bleeding was noted in 25 of 30 of breastfed infants on 25 microg of daily oral prophylaxis, in 1 of 13 on 1 mg of weekly oral prophylaxis, in 1 of 10 receiving 2 mg of intramuscular prophylaxis at birth, and in 1 of 98 formula-fed infants (P < .001). The relative risk of a bleeding in breastfed compared with formula-fed infants was 77.5 for 25 microg of daily oral prophylaxis, 7.2 for 1 mg of weekly oral prophylaxis, and 9.3 for 2 mg of intramuscular prophylaxis at birth.

CONCLUSIONS

A daily dose of 25 microg of vitamin K fails to prevent bleedings in apparently healthy infants with unrecognized cholestasis because of biliary atresia. One milligram of weekly oral prophylaxis offers significantly higher protection to these infants and is of similar efficacy as 2 mg of intramuscular prophylaxis at birth. Our data underline the fact that event analysis in specific populations at risk can help to evaluate and improve nationwide prophylactic regimens.

Vitamin K deficiency bleeding in Great Britain and Ireland: British Paediatric Surveillance Unit Surveys, 1993 94 and 2001-02

OBJECTIVE

To conduct and report monitoring of vitamin K deficiency bleeding (VKDB) in Great Britain and Ireland following the 1988-90 survey (VKDB-90).

DESIGN

Two 2-year surveys conducted during 1993-4 (VKDB-94) and 2001-02 (VKDB-02).

SETTING

Data collected from all consultant paediatricians in Great Britain and Ireland.

PATIENTS

All infants presenting with bleeding resulting from vitamin K (VK) deficiency.

MAIN OUTCOME MEASURES

Incidence of VKDB, related mortality/morbidity and VK prophylaxis recommended/received, noting predisposing features.

RESULTS

Compared with previous studies, VKDB-02 found fewer cases of VKDB (RR: 0.27 (95% CI: 0.12 to 0.59), p<0.001) with no deaths, no long-term morbidity and reduced incidence among those receiving any oral dosing (RR: 0.24 (95% CI: 0.06 to 1.01), p<0.059). Breast-fed infants accounted for the vast majority of cases. The number receiving no prophylaxis fell consecutively over time: 20 of 27 in VKDB-90, 10 of 32 in VKDB-94 and 4 (because of parental refusal) of 7 in VKDB-02. Seven received one oral dose of VK in VKDB-90, 16 in VKDB-94 and none in VKDB-02. Underlying liver disease was found in six cases in VKDB-90, 12 in VKDB-94 and one in VKDB-02.

CONCLUSIONS

In the most recent survey, the incidence of VKDB was about one third that in the two earlier studies. Late onset VKDB remains virtually confined to breast-fed infants who have received either no VK or just one oral dose. The effectiveness of oral prophylaxis regimens has improved over the last 15 years, but parental refusal of prophylaxis has become more problematic.

Vitamin K deficiency bleeding: the readiness is all

Perspective on the papers by Busfield et al and McNinch et al (see pages 754 and 759 )