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Shaw MA, Liu A. Take the Shot: A Review of Vitamin K Deficiency. Pediatr Ann 2023; 52:e42-e45. [PMID: 36779880 DOI: 10.3928/19382359-20230102-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
Vitamin K is essential for the process of coagulation. In its absence, severe and sometimes fatal bleeding events can occur, especially in newborns. Vitamin K prophylaxis at birth has been shown to prevent morbidity and mortality associated with vitamin K deficiency bleeding (VKDB) and is recommended by multiple organizations including the American Academy of Pediatrics and the World Health Organization. Pediatricians should feel comfortable explaining the risks and benefits of vitamin K prophylaxis to families and should be equipped to recognize signs of VKDB, especially given increasing rates of parental refusal. This article aims to improve understanding of VKDB, including prevention, early recognition, and treatment. [Pediatr Ann. 2023;52(2):e42-e45.].
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Sellers A, Lew A, Tudyk M, Nakagawa TA, Sochet AA. Hemorrhagic Disease of the Newborn: A Case Series Illustrating Preventable Harm. J Pediatr Health Care 2023; 37:67-73. [PMID: 36117074 DOI: 10.1016/j.pedhc.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/10/2022] [Accepted: 08/20/2022] [Indexed: 01/31/2023]
Abstract
Newborns are susceptible to postnatal Vitamin K deficiencies from limited placental transfer, gastrointestinal absorption, and bioavailability in breast milk and formula preparations. For over 50 years, the American Academy of Pediatrics has recommended prophylactic vitamin K to prevent hemorrhagic disease in newborns. Yet, public skepticism contributes to increasing refusal rates. We present three cases of vitamin K-dependent bleeding following parental refusal of postnatal prophylaxis. Two patients experienced intracranial hemorrhage with resultant neurological devastation and mortality, respectively. The third child presented with symptomatic hematuria. Perinatal providers must partner with families and advocate vitamin K prophylaxis to limit unnecessary morbidity and mortality.
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Affiliation(s)
- Austin Sellers
- Austin Sellers, MS, Institue of Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Alicia Lew
- Alicia Lew, MD, Department of Pediatrics, University of South Florida College of Medicine, Tampa, FL
| | - Miriam Tudyk
- Miriam Tudyk, MD, Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Thomas A Nakagawa
- Thomas A. Nakagawa, MD, Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Florida College of Medicine, Jacksonville, FL
| | - Anthony A Sochet
- Anthony A. Sochet, MD, MSc, Division of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, FL; Anthony A. Sochet, MD, MSc, Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
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Ellis JL, Wang M, Fu X, Fields CJ, Donovan SM, Booth SL. Feeding Practice and Delivery Mode Are Determinants of Vitamin K in the Infant Gut: An Exploratory Analysis. Curr Dev Nutr 2022; 6:nzac019. [PMID: 35295713 PMCID: PMC8921654 DOI: 10.1093/cdn/nzac019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 01/29/2022] [Accepted: 02/02/2022] [Indexed: 02/02/2023] Open
Abstract
Background Infants have low stores of vitamin K at birth. Dietary intake of phylloquinone (PK) differs dramatically by infant feeding practice, but the contribution of microbially produced vitamin K (menaquinones) to infant vitamin K status is not well understood. Objectives The objective of this study was to investigate determinants of infant fecal vitamin K profiles in mother-infant dyads at 6 wk postpartum. Methods Fecal and breast milk samples were collected from a subsample of breastfeeding (n = 23) or formula-feeding (n = 23) mother and infant dyads, delivered vaginally (n = 26) or by cesarean section (CS) (n = 20) in the Synergistic Theory and Research on Nutrition and Growth (STRONG) Kids 2 cohort. Vitamin K concentrations in breast milk and feces were analyzed by LC/MS and/or HPLC. Fecal bacterial metagenomes were analyzed to derive taxonomy and vitamin K biosynthetic genes. Multivariate linear modeling was used to assess effects of delivery and feeding modes on infant fecal vitamin K. Results Breast milk contained 1.3 ± 0.2 ng/mL PK, and formula was reported to contain 52 ng/mL PK. Fecal PK was 38-times higher (P < 0.001) in formula-fed than breastfed infants. Infant fecal menaquinones (MKn) MK6, MK7, MK12, and MK13 were higher (P < 0.001) in formula-fed than breastfed infants, whereas MK8 predominated in breastfed and was 5-times higher than formula-fed infants. Total MKn were greater (P < 0.001) in vaginally delivered than CS infants. Relative abundances of 33 bacterial species were affected by feeding mode, 2 by delivery mode, and 4 by both (P < 0.05). Bacterial gene content of 5/12 vitamin K biosynthetic genes were greater (P < 0.05) in breastfed compared with formula-fed infants, and 1 differed by delivery mode. Conclusions Feeding practice and delivery mode influence bacterial vitamin K production in the infant gut. High concentrations of unmetabolized PK in feces of formula-fed infants suggests formula PK content exceeds the absorptive capacity of the infant gut.
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Affiliation(s)
- Jessie L Ellis
- Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, Boston, MA, USA
| | - Mei Wang
- Department of Food Science & Human Nutrition, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Xueyan Fu
- Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, Boston, MA, USA
| | - Christopher J Fields
- High Performance Biological Computing Center, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Sharon M Donovan
- Department of Food Science & Human Nutrition, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Sarah L Booth
- Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, Boston, MA, USA
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Elalfy M, Eltonbary K, Elalfy O, Gadallah M, Zidan A, Abdel‐Hady H. Intracranial haemorrhage associated with Vitamin K deficiency in Egyptian infants. Acta Paediatr 2021; 110:2937-2943. [PMID: 34196053 DOI: 10.1111/apa.16011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/27/2021] [Accepted: 06/28/2021] [Indexed: 11/30/2022]
Abstract
AIM Intracranial haemorrhage (ICH) in infancy is a rare life-threatening event. The aim of this review is to highlight the association of ICH and potentially preventable vitamin K deficiency and to describe risk factors, presentation and outcome. METHODS Original published data on ICH related to vitamin K deficiency during 2008-2012 were extracted from records of participating centres in Egypt (Cairo and Delta region). Full data on 70 infants (0-24 weeks) have been reported in three publications. RESULTS The first study involved premature infants where ICH was potentially preventable with administration of parenteral vitamin K prophylactic doses to mothers ahead of imminent preterm delivery. The other 2 studies involved term newborns and infants. ICH due to early or classic vitamin K deficiency was reported in nine patients while 44 were due to late vitamin K deficiency. Main risk factors for late onset were exclusive breastfeeding, persistent diarrhoea and/or prolonged antibiotic therapy. CONCLUSION Vitamin K deficiency bleeding is a relatively frequent problem underlying ICH in infancy. Prophylactic vitamin K to mothers when anticipating preterm labour or a vitamin K boost in exclusively breast-fed infants with prolonged antibiotic usage and, or, persistent diarrhoea might have an impact on prevention and outcome.
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Affiliation(s)
- Mohsen Elalfy
- Department of Paediatrics Haematology/Oncology Ain Shams University Cairo Egypt
| | - Khadiga Eltonbary
- Department of Paediatrics Haematology/Oncology Ain Shams University Cairo Egypt
| | - Omar Elalfy
- Department of Complementary Medicine National Research Center Cairo Egypt
| | - Mohsen Gadallah
- Department of Community Medicine Ain Shams University Cairo Egypt
| | - Ashraf Zidan
- Department of Neurosurgery Mansoura University Mansoura Egypt
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Volpe JJ. Vitamin K deficient bleeding and COVID-19: How are they related? J Neonatal Perinatal Med 2021; 14:313-316. [PMID: 34486992 DOI: 10.3233/npm-210732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- J J Volpe
- Department of Neurology, Harvard Medical School, Boston, MA, USA.,Department of Pediatric Newborn Medicine, Harvard Medical School, Boston, MA, USA
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Gaps in the coverage of vitamin K 1 prophylaxis among newborns in India: insights from secondary analysis of data from the Health Management Information System. Public Health Nutr 2021; 24:5589-5597. [PMID: 34431473 DOI: 10.1017/s1368980021003670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Despite operational guidelines, anecdotal evidence suggests that newborn vitamin K1 prophylaxis is not practiced routinely in India. This study determined the coverage of vitamin K1 prophylaxis among newborns in the country. DESIGN Nationwide cross-sectional data on live births and newborns receiving vitamin K1 during the 2019-2020 reporting period were abstracted from the Health Management Information System (HMIS). The coverage estimates of newborn vitamin K1 prophylaxis were derived nationally and also for individual states and union territories (UT). Additionally, coverage heterogeneities were investigated using classifiers, viz. geography, socio-demographic index (SDI), special developmental categories and institutional birth rate (IBR). SETTING India. PARTICIPANTS 20 208 804 newborns documented with HMIS. RESULTS Vitamin K1 was administered to overall 62·36 % newborns (95 % CI: 62·34 to 62·38 %). The Central zone (49·0 %), low SDI states (54·39 %), Empowered Action Group states (53·32 %) and states with low IBR (44·69 %) had the lowest coverage amongst their respective groupings. Across the individual states and UT, the coverage ranged widely from 22·18 % (in Tripura) to 99·38 % (in Puducherry), exhibiting considerable variability (coefficient of variation: 33·74 %) and inequality (Gini coefficient: 0·17). While the coverage in eight states/UT (i.e. Arunachal Pradesh, Manipur, Nagaland, Tripura, Uttar Pradesh, Uttarakhand, Telangana and Andaman & Nicobar Islands) was below 50 %; only five states/UT (i.e. Chandigarh, Gujarat, Goa, Puducherry and Tamil Nadu) achieved above 90 % coverage. CONCLUSION Vitamin K1 prophylaxis was not practiced in more than one-third newborns in India. It calls for identifying the barriers, addressing the gaps and implementing newborn vitamin K1 prophylaxis more effectively throughout the country.
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Sanseau E, Carr LH, Case J, Tay KY, Ades A, Yang K, Huang H, Bustin A, Good G, Gaines S, Augenstein J, Ciener D, Pearce J, Reid J, Stone K, Burns R, Thomas A. Pediatric Emergency Medicine Simulation Curriculum: Vitamin K Deficiency in the Newborn. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2021; 17:11078. [PMID: 33511273 PMCID: PMC7830750 DOI: 10.15766/mep_2374-8265.11078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 10/06/2020] [Indexed: 06/12/2023]
Abstract
INTRODUCTION The American Academy of Pediatrics recommends vitamin K prophylaxis at birth for all newborns to prevent vitamin K deficiency bleeding (VKDB). Despite a lack of evidence for serious harms, barriers to prophylaxis, including parental refusal, are rising, as are cases of VKDB. METHODS This simulation involved an infant presenting to the emergency department who decompensated due to a cerebral hemorrhage caused by VKDB and was treated by pediatric and emergency providers. The case was incorporated into the fellow and division monthly curricula, and participants completed postsimulation surveys. The patient required a secure airway, seizure management, vitamin K, and a fresh frozen plasma infusion upon suspicion of the diagnosis, plus a coordinated transfer to definitive care. The case included a description of the simulated case, learning objectives, instructor notes, an example of the ideal flow of the scenario, anticipated management mistakes, and educational materials. RESULTS The simulations were carried out with 48 total participants, including 40 fellows and eight attendings, from five different training institutions over 1 year. In surveys, respondents gave overall positive feedback. Ninety-four percent of participants gave the highest score on a Likert scale indicating that the simulation was relevant, and over 80% gave the highest score indicating that the experience helped them with medical management. DISCUSSION This simulation trained physicians how to recognize and treat a distressed infant with VKDB. The case was perceived to be an effective learning tool for both fellow and attending physicians.
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Affiliation(s)
- Elizabeth Sanseau
- Fellow, Pediatric Emergency Medicine, Children's Hospital of Philadelphia
| | - Leah H. Carr
- Fellow, Department of General Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia
| | - Jennifer Case
- Resident, Department of General Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital
| | - Khoon-Yen Tay
- Associate Professor, Clinical Pediatrics, Division of Emergency Medicine, Children's Hospital of Philadelphia
| | - Anne Ades
- Professor, Clinical Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia
| | - Kesi Yang
- Assistant Professor, Clinical Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia
| | - Hannah Huang
- Pharmacist, Department of General Pediatrics, Division of Emergency Medicine, Children's Hospital of Philadelphia
| | - Anna Bustin
- Residency Preceptor, Pharmacy Residency Program, and Clinical Pharmacy Specialist, Neonatal/Infant Intensive Care, Children's Hospital of Philadelphia
| | - Grace Good
- Simulation Specialist, Division of Emergency Medicine, Children's Hospital of Philadelphia
| | - Shannon Gaines
- Education Nurse Specialist, Division of Emergency Medicine, Children's Hospital of Philadelphia
| | - Julie Augenstein
- Assistant Professor, Clinical Pediatrics, Division of Emergency Medicine, Phoenix Children's Hospital
| | - Daisy Ciener
- Assistant Professor, Clinical Pediatrics, Division of Pediatric Emergency Medicine, Vanderbilt University Medical Center
| | - Jean Pearce
- Assistant Professor, Clinical Pediatrics, Division of Emergency Medicine, Medical College of Wisconsin
| | - Jennifer Reid
- Associate Professor, Clinical Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine and Seattle Children's Hospital
| | - Kimberly Stone
- Associate Professor, Clinical Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine and Seattle Children's Hospital
| | - Rebekah Burns
- Associate Professor, Clinical Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine and Seattle Children's Hospital
| | - Anita Thomas
- Assistant Professor, Clinical Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine and Seattle Children's Hospital
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Holley SL, Green K, Mills M, Detterman C, Rappold MF, Thayer S. Educating Parents on Vitamin K Prophylaxis for Newborns. Nurs Womens Health 2020; 24:283-293. [PMID: 32778394 DOI: 10.1016/j.nwh.2020.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/10/2020] [Accepted: 05/01/2020] [Indexed: 06/11/2023]
Abstract
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.
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Affiliation(s)
- Alyssa Stachowiak
- University Hospitals Rainbow Babies and Children's Hospital and Case Western Reserve University School of Medicine, Cleveland, OH
| | - Lydia Furman
- University Hospitals Rainbow Babies and Children's Hospital and Case Western Reserve University School of Medicine, Cleveland, OH
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Shah SI, Brumberg HL, La Gamma EF. Applying lessons from vaccination hesitancy to address birth dose Vitamin K refusal: Where has the trust gone? Semin Perinatol 2020; 44:151242. [PMID: 32291097 DOI: 10.1016/j.semperi.2020.151242] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Shetal I Shah
- Division of Newborn Medicine, Department of Pediatrics, New York Medical College, Regional NICU at Maria Fareri Children's Hospital at Westchester Medical Center, 100 Woods Road, Valhalla, NY 10595, United States.
| | - Heather L Brumberg
- Division of Newborn Medicine, Department of Pediatrics, New York Medical College, Regional NICU at Maria Fareri Children's Hospital at Westchester Medical Center, 100 Woods Road, Valhalla, NY 10595, United States
| | - Edmund F La Gamma
- Division of Newborn Medicine, Department of Pediatrics, New York Medical College, Regional NICU at Maria Fareri Children's Hospital at Westchester Medical Center, 100 Woods Road, Valhalla, NY 10595, United States
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Loyal J, Weiss TR, Cheng JH, Kair LR, Colson E. Refusal of Vitamin K by Parents of Newborns: A Qualitative Study. Acad Pediatr 2019; 19:793-800. [PMID: 30981025 PMCID: PMC7028442 DOI: 10.1016/j.acap.2019.04.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/23/2019] [Accepted: 04/06/2019] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Jaspreet Loyal
- Department of Pediatrics (J Loyal and TR Weiss), Yale University, New Haven, Conn.
| | - Theresa R. Weiss
- Department of Pediatrics, Yale University, New Haven, Connecticut
| | - Jessica H. Cheng
- Department of Pediatrics, University of California Davis, Sacramento, California
| | - Laura R. Kair
- Department of Pediatrics, University of California Davis, Sacramento, California
| | - Eve Colson
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
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