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    Vitamin K Supplementation for the Prevention of Bleeding in Newborns

    Vitamin K Supplementation for the Prevention of Bleeding in Newborns

    Did you choose oral vitamin K supplementation or the intramuscular vitamin K injection for your newborn? Vitamin K is a vitamin essential for blood clotting. Without adequate amounts of vitamin K, the blood cannot clot. Produced by the bacteria that line the gastrointestinal tract, vitamin K is also found in dietary sources such as leafy green vegetables like kale, spinach, turnip greens, collards, Swiss chard, mustard greens, parsley, romaine, and green leaf lettuce as well as other vegetables such as Brussels sprouts, broccoli, cauliflower, and cabbage.

    Newborn InjectionTo help prevent a rare problem that causes bleeding into the brain (vitamin K deficiency bleeding, or VKDB) weeks after birth, most babies receive an injection of vitamin K shortly after birth. Without vitamin K supplementation bleeding in the brain occurs in just over 0.005% of births (5 out of 100,000 births) at three to seven weeks after birth. The cause of this brain bleeding is generally liver disease that goes undetected until the bleeding occurs. This undetected liver disease reduces the ability of the liver to make blood-clotting factors out of vitamin K. Intercranial bleeding can lead to permanent brain damage or death. Vitamin K supplementation at birth has been shown to prevent this rare bleeding into the brain. Babies who do not receive vitamin K at birth have an increased risk for developing VKDB.

    Based on my research, I agree that vitamin K supplement in newborns can prevent extremely rare but extremely serious intercranial bleeding. The questions then becomes the mode of supplementation. With my daughter, I chose to give her oral vitamin K drops for the first few weeks of her life. Again with my son, I decided to use oral vitamin K supplementation rather than the more conventional intramuscular vitamin K injection. My midwife supported my decision both times.

    Additional research also supports my decision to use oral vitamin K drops to supplement my newborn. First, the 1993 policy statement on vitamin K supplementation in the newborn from the American Academy of Pediatrics (AAP) states: “Oral regimens that have a similar efficacy as parenteral vitamin K in prevention of late HDN include the repeated administration of oral vitamin K1 (Germany) or K2 (Japan) at birth, 1 week, and 2 to 4 weeks.” The updated statement from 2003 makes a similar statement: “Prevention of early vitamin K deficiency bleeding (VKDB) of the newborn, with onset at birth to 2 weeks of age (formerly known as classic hemorrhagic disease of the newborn), by oral or parenteral administration of vitamin K is accepted practice.” In other words, the AAP supports vitamin K supplement via both intramuscular injection and oral supplement.

    (As an aside, I will note that one major change between the 1993 AAP policy statement on vitamin K supplementation in the newborn and the 2003 update is that the potential link between the vitamin K shot and an increased risk of childhood cancer has not been substantiated. An earlier study noted an unexpected association between childhood cancer and pethidine given in labor and the neonatal administration of vitamin K. However, additional studies have not been able to replicate the increased risk, thus indicated that the vitamin K shot is likely not associated with an increased risk of cancer.)

    In addition to the AAP policy statement, I also found a number of individual studies that concluded the similar of efficacy of oral vitamin K supplementation compared to the intramuscular vitamin K injection. For example, the 2008 “The Comparison Effect of Oral and Intramuscular Injection Vitamin K on PT and APTT in Neonates” as published in the journal International Journal of Hematology and Oncology concludes: “This study showed that there were not significant differences in PT and APTT between two groups. Therefore both oral and intramuscular vitamin K can prevent classic hemorraghic disease of the newborn, but for showing prevention effect of oral vitamin K in late onset vitamin K further study is needed for targeting of newborns.” In other words, both oral and injected vitamin K supplementation appear to prevent intercranial bleeding among newborns. However, additional research is still needed to conclusively confirm the efficacy of oral supplementation because the majority of previous studies have focused only on the intramuscular vitamin K injection.

    The 1997 “Prevention of Vitamin K Deficiency Bleeding: Efficacy of Different Multiple Oral Dose Schedules of Vitamin K” as published in the European Journal of Pediatrics similarly concluded the efficacy of both oral and injected vitamin K supplementation while noting the lower efficacy of oral drops: “The Australian data confirm that three oral doses of 1 mg vitamin K are less effective than i.m. vitamin K prophylaxis. A daily low oral dose of 25 micrograms vitamin K1 following an initial oral dose of 1 mg after birth for exclusively breast-fed infants may be as effective as parenteral vitamin K prophylaxis.” Of specific importance to me and my babies, however, is the focus on oral supplementation in breastfed babies. As with my daughter, I plan to exclusively breastfeed my second child for the first six months of his or her life. According to the 1997 study, continued oral supplementation is key to preventing intercranial bleeding among newborns. Also as with my daughter, I plan to provide weekly oral vitamin K supplementation for at least the first eight weeks of life. For my breastfed newborn, continued oral vitamin K supplementation should prevent intercranial bleeding.

    The 2003 “Weekly Oral Vitamin K Prophylaxis in Denmark” as published in Acta Paediatrica likewise concluded that weekly oral vitamin K supplementation during the first three months of life was an efficient prophylaxis against vitamin K deficiency bleeding. Among the 274 infants who participated in the study, no cases of VKDB were revealed. The researchers defined a dose of vitamin K as an infant receiving a drop of vitamin K or being mostly formula-fed each week. Parental compliance was good with 94 percent of the infants completing the course of prophylaxis.

    Finally, the 2010 “Evaluation of the Acceptability of a New Oral Vitamin K Prophylaxis for Breastfed Infants” as published in the journal Acta Pædiatrica sought to investigate the acceptability and tolerability of the oral food supplement Neokay for the prevention of vitamin K deficiency bleeding in newborns. While not examining the efficacy of oral vitamin K supplementation, the study did conclude an extremely important factor in the efficacy of oral vitamin K drops among newborns: “As disadvantages, they mentioned possible reduced compliance as a result of the frequency of dosing, decreased parental confidence in breastfeeding and technical issues with packaging.” In other words, lack of continued supplementation may decrease the efficacy of oral supplementation, a concern that echoes the conclusion of the 1997 study. For me personally, I know that I can and will continue providing my newborn with weekly vitamin K drops throughout at least the first eight weeks of life, thus increasing the efficacy of the supplementation.

    Vitamin K DropsAt the time of the birth of my son, I felt confident about my decision to provide my newborns with oral vitamin K supplementation rather than the intramuscular vitamin K injection. Although extremely rare, vitamin K deficiency bleeding in a newborn is extremely serious and quite often fatal. Thus, I agree with the use of vitamin K supplementation in the weeks after birth. Because I exclusively breastfed both my babies for the first six months of life and because I provided continued vitamin K supplementation, I felt confident in my decision to use oral vitamin K drops rather than the vitamin K shot. I also concluded that parents who do not plan on exclusively breastfeeding and who may not provide continued supplementation may decide on the vitamin K shot rather than vitamin K drops.

    If I have another baby in the future, would I choose oral vitamin K supplementation again or the intramuscular vitamin K injection? According to my research, continued oral supplementation in the weeks following birth appears effective in preventing intercranial bleeding among breastfed newborns. However, the AAP recommends that all newborns receive vitamin K as a single, intramuscular dose of 0.5 to 1 milligrams. The AAP additionally states that additional research is needed on the efficacy, safety, and bioavailability of oral formulations and optimal dosing regimens of vitamin K to prevent late VKDB. Therefore, although I chose oral vitamin K supplementation for my first two babies, I would choose the vitamin K shot at this time for any future children.

    References

    The Comparison Effect of Oral and Intramuscular Injection Vitamin K on PT and APTT in Neonates: http://www.uhod.org/pdf/PDF_314.pdf
    Controversies Concerning Vitamin K and the Newborn (1993): http://pediatrics.aappublications.org/content/91/5/1001.short
    Controversies Concerning Vitamin K and the Newborn (2003): http://pediatrics.aappublications.org/content/112/1/191.abstract
    Evaluation of the Acceptability of a New Oral Vitamin K Prophylaxis for Breastfed Infants: http://www.ncbi.nlm.nih.gov/pubmed/19958305
    Vitamin K: http://www.nlm.nih.gov/medlineplus/ency/article/002407.htm
    Prevention of Vitamin K Deficiency Bleeding: Efficacy of Different Multiple Oral Dose Schedules of Vitamin K: http://www.ncbi.nlm.nih.gov/pubmed/9039517
    Protect Babies from Life-threatening Bleeding: Talk to Expectant Parents about the Benefits of the Vitamin K Shot for Newborns: http://www.cdc.gov/ncbddd/blooddisorders/documents/vitamin-k-provider.pdf
    Vitamin K in Neonates: Facts and Myths: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3021393/
    Weekly Oral Vitamin K Prophylaxis in Denmark: http://www.ncbi.nlm.nih.gov/pubmed/12892158

    Image Credits

    Vitamin K Supplementation for the Prevention of Bleeding in Newborns: https://www.flickr.com/photos/cdcglobal/9665202204/ (CC BY 2.0) and Vitamin K Drops © 2012 Heather Johnson
    Newborn Injection: https://www.flickr.com/photos/cdcglobal/9665202204/ (CC BY 2.0)
    Vitamin K Drops © 2012 Heather Johnson

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