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Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Another Treatise on Vitamin K

Hemorrhagic Disease of the Newborn (HDNB) can occur anytime in the 1st few months of life. Early HDNB occurs in the 1st 24 hrs, Classical HDNB is at 1 to 7 days (most often at 2 to 5 days) and Late HDNB is usually between 2 & 8 wks, but can occur anytime in the 1st year. When the clotting factors get too low the baby can develop spontaneous bleeding- anything from bruising and umbilical bleeding, to intrathoracic, intra-abdominal, or intracranial hemorrhage.

Newborns have only 20-50% of the coagulation activity of adults, including the vit. k dependent clotting factors (prothrombin, proconvertin, & others). Levels in premature babies are even lower. Vitamin K prevents HDNB by increasing the activity of these K-dependent clotting factors. Incidence of HDNB is 1:1200 if no vit k is given and 1:20,000 if k is given to high risk babies only. (I couldn't find what risk factors were used for this particular study or what the risk was if vit k was given to _all_ babies. Anybody know?)

Risk factors include: Maternal: exposure to anticonvulsants, barbiturates, aspirin, or antibiotics. Newborn: prematurity, low birth weight, difficult births (forceps, shoulder dystocia, excessive molding, breech, cephalhematoma), malabsorption conditions (e.g. bowel obstruction, cystic fibrosis), exposure to any of the drugs listed under maternal risks (including getting them through breastfeeding), and, ironically enough, exclusive breastfeeding. Breastmilk has about 2-15 mg/liter of vit. k, formula has about 50 mg/liter. One study said that out of 198 cases of HDNB, 186 were breastfed and only 3 were exclusively bottle fed.

Initial symptoms can include: vomiting, lethargy, pallor, loss of appetite, fever, convulsions, unconsciousness, dyspnea, nodular purpura (widespread deep ecchymosis), bleeding from circumcision or injection sites, or other hemorrhage. Intracranial hemorrhage is seen in 50-80% of affected babies and causes death or severe handicap in 50-70% of those babies.

Vitamin K is fat soluble. It comes from plants & vegetable oils(Type K-1) and is also synthesized by bacteria in the gut (type K-2), but K-2 is not a major source in the 1st 4-6 months of life. Food sources of K are leafy greens (spinach, kale, turnip, etc.), cabbage, cauliflower, peas, kelp, alfalfa, nettles, green tea, chlorophyll, dairy products, egg yolks, safflower & other polyunsaturated oils, and fish liver oils. Vit. K is destroyed by freezing & radiation.

Placental transport of vit. k is documented, but babies levels will be much lower than moms. Cord blood has levels at 1/10th to 1/2 of maternal level. There was, however, a significant decrease in intracranial hemorrhage in preemies when their moms got IM vit. k 4-5 hrs before delivery.

Studies vary as to the effectiveness of oral vitamin k. (Which was the original question, right? I mean, I really _did_ have an excuse to start writing all of this[Grin]) Late HDNB seems to still be a problem when K is given orally, so repeated doses are usually recommended, though advice about when to give them & how much to give varies. We don't seem to have oral K available in the US, but the injectable form may be given orally (Double the dose- draw up 2 ampules, remove the needle, and squirt into baby’s mouth) The stuff tastes terrible, and in my own personal experience babies react worse to the oral dose then the injection, so I usually give it IM. I use a 27g needle and give it while the baby is nursing.(First I explain to the baby what I'm doing & why, like, "Hey baby, I'm going to give you a vitamin shot & it's going to hurt for a minute, but it's to keep you from having any bleeding problems.") Most of them don't even cry.

If a mom doesn't want to give the baby vit. k, I recommend that she take Vit. k during her pregnancy and the first few months of breastfeeding. It's available in pill form at health food stores. It may not be as effective, but it seems like an acceptable alternative for low risk babies. I've heard of shepherds purse tincture being given instead of K, but I don't know much about it.

All of this may not be a big issue to hospital based midwives where vit. k is usually given routinely, but when I gave a talk about vit. k to the Ohio Midwives Alliance (where most do home births), I found that almost nobody was giving it, and as a result of the talk, a few decided to at least start carrying the stuff. I wish I had done all this studying _before_ my friend had her baby. Given what I now know about risk factors, etc., I probably would have more strongly recommended that her baby have it. Sorry this is so long, but maybe the info will be helpful to somebody out there.