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Hemorrhagic Disease Of The Newborn

Vitamin K Deficiency Bleeding (VKDB) is also known as hemorrhagic disease of the newborn. It is a condition that can present with life threatening hemorrhage due to low levels of vitamin K at birth. It is preventable with the routine administration of vitamin K at birth. Presentation falls into one of three categories.

Type Time Of Presentation Characteristics
Early0-24 hours after birthSevere

Mainly found in infants whose mothers used certain medications  (like medicines to treat seizures or isoniazid) that interfere with how the body uses vitamin K
Classical1-7 days after birthBruising

Bleeding from the umbilical cord
Late2-12 weeks after birth is typical, but can occur up to 6 months of age in previously healthy infants30-60% of infants have bleeding within the brain

Tends to occur in breastfed only babies who have not received the vitamin K shot

Warning bleeds are rare
Source: CDC

According to the CDC:

  • Early and classical VKDB are more common, occurring in 1 in 60 to 1 in 250 newborns, although the risk is much higher for early VKDB among those infants whose mothers used certain medications during the pregnancy.
  • Late VKDB is rarer, occurring in 1 in 14,000 to 1 in 25,000 infants.
  • Infants who do not receive a vitamin K shot at birth are 81 times more likely to develop late VKDB than infants who do receive a vitamin K shot at birth.

History

Risk factors for VKD include:

  • Certain drugs taken during pregnancy which may interfere with vitamin K metabolism.
    • Anticonvulsants
    • Anti-tubercular drugs (isoniazid)
    • Warfarin
    • Salicylates
  • Early gestation – Preterm babies are at a higher risk of having VKDB.
  • Place of delivery- Home births do not have access to vitamin K injection until follow up visit.
  • Breast feeding

Physical

Physical examination findings may include:

  • Head and facial bruising, cephalohematoma
  • Irritability, seizures, excessive sleepiness, or a lot of vomiting – signs of intracranial bleeding
  • Hemoptysis, respiratory distress – signs of intrathoracic bleeding
  • Melena or hematemesis – gastrointestinal bleeding
  • Petechiae, pale skin
  • Scleral icterus – typically seen after 3 weeks of life
  • Bleeding from mucous membranes, including the gums, nose. For darker skinned babies, the gums may appear pale
  • Bleeding after circumcision
  • Bleeding from the umbilical stump
  • Bleeding from vaccination sites

Labs

  • Prothrombin time (PT) should be more than 4 times normal
  • Normal platelet count
  • Normal fibrinogen level
  • Partial thromboplastin time (PTT) may also be increased due to decreased activity of factors 2,9 and 10
  • Clotting time will be increased due to clotting factor deficiency

Treatment

  • 1mg vitamin K intra-muscularly (IM)
  • Treat hemorrhage with blood transfusion and address life threatening bleeds (Intracranial hemorrhage)
  • Exclude other causes of newborn coagulopathy: Hemophilia, DIC, ITP – all should have other lab abnormalities.

References

  • CDC Vitamin K Deficiency Bleeding
  • Kher P, Verma RP. Hemorrhagic Disease Of Newborn. [Updated 2021 Jan 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Full Text

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