S2757 Vitamin K Deficiency in the Setting of Long-Term Blenderized Tube Feeds in a Teenager

Abstract

INTRODUCTION: Severe, symptomatic presentation of nutritional deficiencies are uncommon in the current era. Vitamin K deficiency is classically seen in newborns and can present as early as 24 hours after birth and as late as up to 6 months. However, in pediatric patients with chronic comorbidities, vitamin K deficiency can also occur later in life with risk factors such as enteral feeding and recent antibiotic use. We describe a case of acquired vitamin K deficiency in a teenager on long term enteral nutrition. CASE DESCRIPTION/METHODS: A 17-year-old male with spinal muscular atrophy type 1, ventilator, and gastrostomy tube dependence, was admitted for coagulopathy noted during routine follow up after a diarrheal illness. He was treated with a short course of metronidazole for suspected small intestinal bacterial overgrowth as stool pathogens were negative. Physical examination revealed oozing from an anal fissure, tracheostomy, and gastrostomy sites. Laboratory studies revealed a prothrombin time (PT) of 114 s (normal: 9.4-12.5 s), partial thromboplastin time (PTT) 99.2 s (normal: 25.1-36.5 s) and international normalized ratio (INR) of 9.5 (normal: 1.1 or below). Fibrinogen and D-dimer were normal, ruling out disseminated intravascular coagulation. Factors V were normal at 94%, VIII more than 150%, VII low at 3%, and IX low at 11%. Mixing studies revealed deficiencies of the intrinsic and extrinsic pathways, and this, coupled with low factors VII and IX confirmed vitamin K deficiency. He received parenteral vitamin K which resolved his coagulopathy - PT 13.2 seconds, PTT 37.1 seconds, and INR of 1.2. His blenderized tube feeding regimen consisted of a base of Vivonex® Pediatric® mixed with baby foods and juice. This formulation did not meet the Dietary Reference Intake for vitamin K (44.2mcg/dL, recommended is 60-75mcg/dL), protein, phosphorus, calcium, zinc, folate, and essential fatty acids. He was discharged home on supplemental vitamin K, a multivitamin, protein supplement and, safflower oil. DISCUSSION: Our case highlights an important, yet frequently unrecognized differential of coagulopathy: vitamin K deficiency. This could be asymptomatic until the patient develops a bleeding diathesis. Clinicians should be aware that for pediatric patients on long-term blenderized tube feeds, it is essential to monitor micro and macronutrients on a regular basis.