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Treatise on Vitamin K

While looking up my reference on "late-onset hemorrhagic disease" I came across several items of interest in this discussion. I hope I don't make anyone angry by posting this, but I am not satisfied with the non-conclusions we've not come to in this discussion ::grin:: While reading the following from my textbooks, I had these questions:

1. Re: the breast-fed infants with hemorrhagic disease: how soon and how often are they breast-fed? How much colostrum do they receive? Are they allowed to stay at the breast or is feeding time limited (how much hindmilk do they receive)? What sort of birth trauma is present in these infants?
2. Why not only inject those infants who are at risk or who have symptoms? Bleeding ceases in 2-4 hours, if one is watching the infant closely, is this sufficient?
3. What about giving mothers supplementary vitamin K or having them eat a diet high in vitamin K? Before birth? After birth?
4. If what we need is friendly bacteria in the intestinal tract, what about acidophilus? Would it be possible to give the newborn acidophilus? Or would giving it to the mother be helpful at all (I wouldn't think so...)?
5. If HDN is "completely prevented" by vitamin K injection, why do these nursing texts give instructions (one even in the "Drug Guide" box) for observation for symptoms? These texts assume that all infants are going to receive vitamin K, yet they instruct watching for symptoms.
6. The second text, in chapter 32, says that vitamin K "may be obtained from food" but is usually synthesized in the gut. So why wouldn't giving mom plenty of vitamin K-rich foods work?

"Hemorrhagic disease of the newborn is a bleeding disorder that may appear within 1 to 5 days of life as a result of a deficiency of vitamin K. Newborn vitamin K stores are virtually absent, and there is a moderate deficiency of prothrombin activity, which decreases until approximately 72 hours after birth when it begins to increase. Consequently, vitamin K-dependent coagulation factors (II, VII, IX, X) are significantly reduced. In addition, the newborn's sterile intestinal tract is unable to synthesize the vitamin until feedings have begun. Breast-fed infants are particularly at risk because human milk is a poor source of vitamin K. Hemorrhagic manifestations rarely occur in infants fed fortified cow's milk formula from the first day of life because this formula is an adequate source of the vitamin.

"Signs and symptoms of hemorrhagic disease typically appear 24 to 72 hours after birth and can include oozing from the umbilicus or circumcision site, bloody or black stools, hematuria, ecchymoses on skin and scalp, epistaxis, or bleeding from punctures. Diagnoses can be confirmed in the presence of prolonged prothrombin time (PT) and partial thromboplastin time (PTT) accompanies by normal platelet count and fibrinogen levels.

"A late form (late-onset hemorrhagic disease) appears at about 4 to 7 weeks of age. This late-onset disease occurs in totally or predominantly breast-fed infants. It appears to be related to a factor in breast milk that inhibits vitamin K synthesis by the infant's bacterial flora. Manifestations of late-onset disease are evidence of intracranial hemorrhage, deep ecchymoses, bleeding from the gastrointestinal tract, and/or bleeding from mucous membranes, skin punctures, or surgical incisions.

THERAPEUTIC MANAGEMENT

"The goal of management is prevention of hemorrhagic disease of the newborn with prophylactic administration of vitamin K. In the United States, intramuscular administration of vitamin K (Aquamephyton, Mephyton) in a dose of 0.5 to 1 mg once during the first 24 hours of life is a standard practice. The use of prophylactic vitamin K is not routinely practiced in all countries.

"In newborns with the disease, treatment is the same as the preventive measures, except that the vitamin may be given intravenously to prevent a hematoma at an intramuscular site. Bleeding usually ceases within 2 to 4 hours of vitamin K administration.

"Some have reported success with daily oral administration of vitamin K to the infants (McNinch and others, 1985; Olson, 1987) or to the mothers during the last month of pregnancy (O'Connor and Addiego, 1986). To prevent late-onset disease it is recommended that mothers of breast-feeding infants receive oral vitamin K supplementation (von Kries and others, 1987). None of these is standard practice.

"Breast-feeding mothers are encouraged to increase their intake of foods containing vitamin K, primarily vegetables. The best sources are green vegetables, especially broccoli."

Also from MATERNAL NEWBORN NURSING: A FAMILY-CENTERED APPROACH, 4th ed, OLDS, LONDON & LADEWIG (1992), p 889-890:

"A prophylactic injection of vitamin K is given to prevent hemorrhage, which can occur due to low prothrombin levels in the first few days of life (see the accompanying Drug Guide -- Vitamin K-1 phytonadione). The potential for hemorrhage is considered to result from the absence of gut bacterial flora, which influences the production of vitamin K in the newborn (see Chapter 32 for further discussion). Controversy exists over whether the administration of vitamin K may predispose the newborn to significant hyperbilirubinemia. Cunningham et al. 1989 indicate there is no evidence to support this concern as long as a standard dose of 1 mg is given. Some people have questioned the need to give vitamin K to newborns who have had a nontraumatic birth.

"A study by Von Kries (1988) looked at replacing parenteral vitamin K with oral vitamin K to avoid injecting the infant. The study demonstrated a considerably higher level of vitamin K present after intramuscular administration than after oral administration. Thus, parenteral vitamin K prophylaxis is a safer means of providing infants with high vitamin K load.

"The vitamin K injection is given intramuscularly in the middle one-third of the vagus lateralis muscle located in the lateral aspect of the thigh (Figure 29-4). An alternate site is the rectus femoris muscle in the anterior aspect of the thigh. However, this site is near the sciatic nerve and femoral artery and should be used with caution.

"DRUG GUIDE -- VITAMIN K-1 PHYTONADIONE (AQUAMEPHYTON)

"OVERVIEW OF NEONATAL ACTION "Phytonadione is used in prophylaxis and treatment of hemorrhagic disease of the newborn. It promotes liver formation of the clotting factors II, VII, IX, and X. At birth the neonate does not have the bacteria in the colon that is necessary for synthesizing fat-soluble vitamin K-1, therefore the newborn may have decreased levels of prothrombin during the first 5-8 days of life reflected by a prolongation of prothrombin time.

ROUTE, DOSAGE, FREQUENCY

"Intramuscular injection is given in the vastus lateralis thigh muscle. A one-time only prophylactic dose of 0.5-1.0 mg is given in the birthing area or upon admission to the newborn nursery. If the mother received anticoagulants during pregnancy, an additional dose may be ordered by the physician and is given at 6-8 hours post first injection.

NEONATAL SIDE EFFECTS

"Pain and edema may occur at injection site. Possible allergic reactions such as rash and urticaria.

NURSING CONSIDERATIONS

"Observe for bleeding (usually occurs on second or third day). Bleeding may be seen as generalized ecchymoses or bleeding from umbilical cord, circumcision site, nose, or gastrointestinal tract. Results of serial PT and PTT should be assessed.

"Observe for jaundice and kernicterus especially in pre-term infants.

"Observe for signs of local inflammation.

"Protect drug from light."

from Chapter 32 (p 1054):

"Several transient coagulation-mechanism deficiencies normally occur in the first several days of a newborn's life. Foremost among these is a slight decrease in the level of prothrombin, resulting in a prolonged clotting time during the initial week of life. Vitamin K is required for the liver to form prothrombin (factor II) and proconvertin (factor VII) for blood coagulation. Vitamin K, a fat-soluble vitamin, may be obtained from food, but it is usually synthesized by bacteria in the colon, and consequently a dietary source is unnecessary. However, intestinal flora are practically nonexistent in newborns, so they are unable to synthesize vitamin K.

"Bleeding due to vitamin K deficiency generally occurs on the second or third day of life, but it may occur earlier in babies of mothers treated with phenytoin sodium (Dilantin) or phenobarbital. These drugs impair vitamin K activity, and bleeding may be seen at birth. Coumarin compounds are vitamin K antagonists that can cross the placenta. Thus the baby exposed to maternal coumarin can also manifest bleeding in the first 24 hours of life. Bleeding may also occur in babies receiving parenteral nutrition without adequate vitamin K additives (1mg/week).

"Bleeding from the nose, umbilical cord, circumcision site, gastrointestinal tract, and scalp, as well as generalized ecchymoses may be seen. Internal hemorrhage may occur.

"This disorder can be completely prevented by the prophylactic use of an injection of vitamin K. A dose of 1 mg of AquaMEPHYTON is given as part of newborn care immediately following birth, and consequently the disease is rarely seen today. Larger doses are contraindicated because they may result in the development of hyperbilirubinemia."