Change in hospital protocol regarding the use of vitamin K prophylaxis in newborns following a case of spontaneous subdural haematoma in a previously healthy 40-day-old infant

Abstract

In 1894, Townsend described a selflimited bleeding condition that usually occurs 1–5 days after birth in patients with non-classic haemophilia [1]. The term haemorrhagic disease of the newborn was adopted to describe bleeding disorders among neonates associated with a traumatic birth or haemophilia [2]. This diagnostic term has now been replaced with the term vitamin K deficiency bleeding (VKDB) because vitamin K deficiency is not the sole cause of haemorrhagic disorders in preterm and term infants [3]. Vitamin K represents a group of lipophilic and hydrophobic vitamins that promotes the hepatic synthesis of the certain clotting factors [4,5]. Although some controversy surrounds postnatal timing of the initial haemorrhage, VKDB of the newborn is usually classified by 3 distinct time periods after birth: early-onset VKDB usually occurs during first 24 hours after birth and is very rare; classic VKDB usually occurs after 24 hours and as late as the first week of life and is also rare; and late-onset VKDB in a newborn who did not receive a vitamin K shot, and in those of Asian descent, which usually occurs between age 2–12 weeks but can be seen as long as 6 months after birth. The characteristics of VKDB are that it is most common in breastfed infants who did not receive vitamin K prophylaxis at birth. Vitamin K content is low in mature human milk and ranges from 1–4 μg/L. Industrial contaminants in breast milk have been implicated in promoting VKDB. More than half of these infants present with acute intracranial haemorrhages [6]. In addition, infants who have intestinal malabsorption defects (cholestatic jaundice, cystic fibrosis, etc.) may also have late VKDB. The rate of late-onset VKDB, often manifesting as sudden central nervous system haemorrhage, ranges from 4.4 to 7.2 per 100 000 births, according to reports from Europe and Asia. Normally, VKDB infants do not require surgical care but in rare cases, an infant may need neurosurgical evaluation and treatment [7,8]. Other conditions, such as those associated with short-bowel syndrome and hepatobiliary disease may require surgical evaluation. Intracranial bleeding is rare and is usually associated with other causes of bleeding, particularly thrombocytopenia; however, intracranial haemorrhage has been reported in VKDB and can be fatal [9]. We present here a case of spontaneous subdural haematoma in a previously healthy 40-day-old infant and discuss the subsequent changes in our hospital protocol regarding the use of vitamin K prophylaxis in newborns. Case report