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The Vitamin K Decision

8.26spinach-cropWhat is Vitamin K?

Vitamin K is a fat-soluble vitamin needed for many processes in the body, including blood clotting. The liver relies on Vitamin K for the synthesis of key clotting factors. Our bodies can only produce a limited amount of their own Vitamin K and a diet rich in green leafy vegetables is the main source of Vitamin K intake.

Why is Vitamin K given to newborns?

Vitamin K is given to newborns to reduce the incidence of Vitamin K Deficiency Bleeding (VKDB) or formerly known as Heamorrhagic Disease of the Newborn (HDN).

VKDB is a rare but serious condition that can cause fatal bleeding, particularly in the brain. VKDB can be of early onset, within 24 to 48 hours of birth. But more classically, VKDB occurs between day 2 to 8 after birth. Not all babies are at equal risk of VKDB. Prematurity or birth trauma (forceps or vacuum birth) are risk factors that have been associated with VKDB. VKDB can occur for up to 6 months after birth (late onset) and is generally associated with liver disease (1 in 3 babies).

Incidence of VKDB

  • No administration of Vitamin K: 5 in 100.000                                                                                         (This only includes general low risk babies, not babies with risk factors for VKDB!)
  • Intramuscular injection: 0.3 in 100.000  (3 babies in 1 million)
  • Oral: 1 to 2.5 in 100.000 (depending on administration of all 3 doses)

In order to prevent 1 case of VKBD, several thousand babies need to be given the Vitamin K prophylaxis. Administration of Vitamin K substantially decreases the incidence of VKDB but does not prevent VKDB all together.

Options for Vitamin K administration

images3The recommendation in Australia is for all babies to receive Vitamin K within a few hours of birth.

Most commonly, Vitamin K is given to newborn babies as a single 1mg dose by intramuscular injection. No research has been done to determine the optimal Vitamin K dosage to be administered to the newborn and the Vitamin K injection will increase the baby’s Vitamin K blood levels 10.000 times higher than what the baby needs!

Vitamin K can also be administered orally. Many parents are unaware of the oral Vitamin K option as the full information are simply not presented by most care providers. The oral dose is 2mg and administration will have to be repeated at day 3 and 4 weeks after birth as a total of 3 doses is required in order to minimise the risk of VKDB (Australian guidelines).

As Vitamin K is a fat-soluble substance, the oral dose is best given with breastmilk as this can enhance Vitamin K absorption. Initiation of early breastfeeding is very important as colostrum has higher amounts of Vitamin K than mature breastmilk. Initially the baby’s gut is immature and will not be able to contribute to Vitamin K synthesis. However, once the newborn’s gut is colonised with Vitamin K producing bacteria, the baby is able to manufacture additional Vitamin K. This usually occurs around day 8 after birth but might take several weeks to establish.

vitaminK_capsule_neokayGenerally the Vitamin K levels in breastmilk are low. However, if the mother increases her Vitamin K intake whilst breastfeeding it is hypothesised that the baby will be able to get enough Vitamin K in breastmilk, equivalent to the Vitamin K levels in formula.

Additional Vitamin K is added to infant formula and if the baby is exclusively formula fed the baby will get sufficient Vitamin K supplementation from the formula.

Optimising Vitamin K levels in the newborn

  • Reducing physcial trauma during birth/ trauma caused by medicalised birth (forceps or vacuum birth)
  • Initiation of early breastfeeding (colostrum is high in Vitamin K)
  • Delayed cord clamping (early cord clamping can deplete the newborn of its clotting factors)
  • Avoid antibiotics (interference with newborn gut flora and Vitamin K producing bacteria)
  • Optimise maternal Vitamin K intake whilst breastfeeding
  • Optimise maternal gut flora (Vitamin K producing bacteria)

Alternatives

In my practice I am working with a risk-based approach. I do only recommend oral Vitamin K administration in the presence of the following risk factors:

  • Separation of mother and baby
  • Poor feeding, poor weight gain
  • Prolonged jaundice >2 weeks
  • Prematurity
  • Birth trauma
  • Unwell newborn
  • Maternal medications (Warfarin, epilepsy drugs)
  • Circumcision

I always advise parents to be vigilant and to observe their baby for unusual signs of bruising or bleeding as bleeding is a major symptom of VKDB. A warning bleed can occur from the cord, a heelprick (Newborn Screening Test) or nose. 1 in 3 babies do have a warning bleed and an immediate recognition and appropriate response to these warning signs can prevent long-term problems and significant outcomes.

Are newborms really Vitamin K deficient?

Why do all babies have low levels of Vitamin K? What is a normal level? What is a low level? And low in relation to what? To the Vitamin K levels of an adult?

All babies are born with ‘low’ levels of Vitamin K. Considering that all babies are born with ‘low’ Vitamin K levels would that not mean that mother nature intended for us to be born like that and that these low levels are potentially physiological rather than calling the low Vitamin K levels an alleged deficiency?

What might be the potential effects of a non-physiological increase in newborn Vitamin K levels through supplementing all babies at birth with a Vitamin K substance?

What are the risks of a non-physiological 10.000 times increase in Vitamin K levels through Vitamin K administration? If the baby is born with exactly the right amount of Vitamin K that it needs then the additional Vitamin K might be an overdose that results in an unhealthy increase in clotting factors. Little research has investigated if increased clotting factors might actually be harmful to the newborn or cause future health problems.

What are the reasons for the low Vitamin K levels and delayed clotting in a newborn?

Much about Vitamin K remains unknown but mother nature seems to put in a great effort in attempting to keep the Vitamin K level of the fetus and newborn low. As parents you will have to weigh up the risks and side effects that are associated with the Vitamin K administration versus the risks and effects of VKDB.

Ten Moons Statistics 2014 for Vitamin K Administration

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(IM= intramuscular injection)

References

Karin Rothville- Vitamin K: controversy? what controversy? 

Karin Rothville- Vitamin K: A literature review

Sarah Buckley- The Vitamin K Decision (webinar- member access only)

Sara Wickham- Revisiting Vitamin K and the newborn: what have we learned in a decade?

Sara Wickham- Vitamin K and the Newborn (AIMS 2003)

 

This article has 5 comments

  1. Hi–I teach birth classes, and one of the moms-to-be cited your website for info about Vit. K. I have looked at it, and noticed some discrepancies. I wondered about your references, and if you could share them? Where do you get your #’s for the incidence of VKDB?According to this site, http://evidencebasedbirth.com/evidence-for-the-vitamin-k-shot-in-newborns/

    breastmilk contains very little Vit K (whereas formula does have Vit K). You also say colostrum is high with Vit K–again–reference? You say Vit K is a substance not really needed–again–why?

    Thanks for any input–Sincerely, Lori

    • Dear Lori,

      Thank you for your interest in our post ‘The Vitamin K Decision’ from March 2014 and your comments.

      We have attached the reference list at the end of the post and also made some minor amendments to the original post.

      The first amendment that has been made is in regards to colostrum- ‘the content of Vitamin K in colostrum is high’ has been amended to ‘higher than in mature breastmilk’.

      The second amendment that has been made- ‘… giving thousands of babies a substance that is not really needed’ has been amended to ‘… potential effects of a non-physiological increase in newborn Vitamin K levels through supplementing all babies at birth with a Vitamin K substance’.

      The intention of this post is to inform parents about the fact that there are choices and options available around the Vitamin K decision which often remain unspoken about in the western medical model of care.

      We are not advocating for either Vitamin K decision. Our aim is merely to stimulate parents to think about certain decisions that they will have to make and also encourage parents to do further research into certain topics.

      Ten Moons

  2. Thankyou, a very informative commentary to help with making a decision on what to do as a parent.  Our first got the injection (no consult, it was just done) and she still carries a bruising scar on her thigh from the injection sit, so I cannot encourage anyone to get the injection as she will now carry this rather large blemish for the rest of her life.  #2 we made a decision, in discussion with ob/gyn & midwives to not provide any supplements/injection.  I would always encourage oral over intra-muscular injection after our experience- but at least this article opens up a discussion that most parents don’t realise can be an informed decision to make a decision either way. 

  3. What solution is used for Vitamin K delivered orally in Australia? I’ve read that the solution is not licenced/not recommneded by Roche for orad administration but I can’t find any information on whether this solution (Konakion – the same as the injection) is still used or if a different one has become available. The NSW health booklet on vitamin K was pretty much useless….

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