Vitamin K Deficiency Bleeding Research Articles

Recurrent subdural hematoma as presentation of neonatal biliary atresia: A case report

Biliary atresia is a congenital disorder of progressive and obliterative cholangiopathy, the most common cause of neonatal cholestasis, it can cause secondary vitamin-K deficiency bleeding due to the malabsorption of lipids and lipid-soluble vitamins due to cholestasis. We report a 46-day-old child presenting with cholestatic features complicated by subdural hematoma (SDH) and cerebral edema. On investigations, she was found to be having primary biliary atresia, for which she was operated but had a recurrence of the SDH on the opposite side.

Геморрагическая болезнь новорожденных: современные подходы к диагностике, профилактике и лечению

Введение. Геморрагическая болезнь новорожденных – патологическое состояние новорожденных и детей первых месяцев жизни, обусловленное дефицитом витамин К-зависимых факторов свертывания крови и проявляющееся повышенной кровоточивостью. Частота возникновения геморрагической болезни новорожденных варьирует в разных регионах мира, в России, согласно литературным данным, она составляет от 0,25% до 1,7%. Для геморрагической болезни новорожденных характерно развитие кровотечений и кровоизлияний, которые негативно влияют на функцию и в дальнейшем на развитие ряда органов и систем ребенка, в особенности на центральную нервную систему и желудочно-кишечный тракт. Основываясь на этиологии развития заболевания, геморрагическая болезнь новорожденных классифицируется на первичную (идиопатическую) и вторичную. В зависимости от возраста дебюта выделяют раннюю, которая проявляется в первые 24 часа жизни, классическую (развивается на 2-7 сутки) и позднюю, проявляющуюся после 1 недели жизни (редко возникает до шести месяцев жизни, а некоторые авторы указывают возраст детей до 1 года), формы геморрагической болезни новорожденных. Ключевым приоритетом неонатологов является выделение из числа родившихся детей новорожденных, составляющих группу риска по геморрагической болезни новорожденных с целью профилактического введения им витамина К, что позволяет предотвращать тяжелые нежелательные последствия заболевания. Генетическое исследование методом логистического регрессионного анализа подтвердило более высокий риск внутрижелудочковых геморрагий у новорожденных при полиморфизмах в гене VKORC1, отвечающем за связывание витамина К1 цистеином и, таким образом, за снижение его концентрации у носителей данного гена. Несмотря на вариабельность в подходах к дозам, способам и срокам введения, парентеральное введение витамина К – единственный надежный и предпочтительный способ профилактики данного заболевания. В случае развития геморрагической болезни новорожденных в настоящее время разработаны современные подходы к диагностике и лечению данной патологии. Результаты. В статье приводятся современные подходы к профилактике, диагностике и терапии витамин К-зависимой геморрагической болезни новорожденных. Background. Hemorrhagic disease of the newborn is a pathological condition in newborns and children during the first months of life, caused by vitamin K deficiency of dependent blood coagulation factors and manifested by increased bleeding. The incidence of hemorrhagic disease of the newborn varies in different regions of the world, in Russia, according to the literature data, it ranges from 0.25 to 1.7%. Hemorrhagic disease of the newborn is characterized by the development of bleeding and hemorrhage, which negatively affect the function and further development of a number of organs and systems of the child, especially the central nervous system and the gastrointestinal tract. Based on the etiology of the development of the disease described above, HDN is classified into primary (idiopathic) and secondary. Depending on the age of onset, early is distinguished – it manifests itself in the first 24 hours of life, classical – develops on the 2-7th day and late, manifesting itself after 1 week of life (rarely occurs at the age of up to 6 months of life, and some authors indicate the age children under 1 year of age) hemorrhagic disease of the newborn forms. The key priority of neonatologists is to single out from the number of born children, newborns who are at risk for HRD for the purpose of prophylactic administration of vitamin K to them, which will prevent severe undesirable consequences of the disease.A genetic study using logistic regression analysis confirmed a higher risk of intraventricular hemorrhages in newborns with polymorphisms in the VKORC1 genes, which is responsible for the binding of vitamin K1 to cysteine, and thus for a decrease in its concentration in carriers of this gene. Despite the variability in approaches to doses, methods and timing of administration, parenteral administration of vitamin K is the only reliable and preferred way to prevent this disease. In the case of the development of hemorrhagic disease of the newborn, modern approaches to the diagnosis and treatment of this pathology have been developed. Results. The article presents modern approaches to the prevention, diagnosis and therapy of vitamin K-dependent hemorrhagic disease of the newborn.

Radial nerve palsy caused by a rapidly growing intramuscular hematoma in an infant with biliary atresia: a case report

BackgroundBiliary atresia (BA) is a rare cause of persistent jaundice in infants that can result in vitamin K malabsorption and vitamin K deficiency bleeding (VKDB). We present an infant with BA who developed a rapidly growing intramuscular hematoma in her upper arm after a vaccination which caused a radial nerve palsy.Case presentationAn 82-day-old girl was referred to our hospital because of a rapidly growing left upper arm mass. She had received three doses of oral vitamin K before age 1 month. At age 66 days, she received a pneumococcal vaccination in her left upper arm. On presentation, she showed no left wrist or finger extension. Blood examination revealed direct hyperbilirubinemia, liver dysfunction, and coagulation abnormalities, indicating obstructive jaundice. Magnetic resonance imaging showed a hematoma in the left triceps brachii. Abdominal ultrasonography revealed an atrophic gallbladder and the triangular cord sign anterior to the portal vein bifurcation. BA was confirmed on cholangiography. VKDB resulting from BA in conjunction with vaccination in the left upper arm were considered the cause of the hematoma. The hematoma was considered the cause of her radial nerve palsy. Although she underwent Kasai hepatic portoenterostomy at age 82 days, the obstructive jaundice did not sufficiently improve. She then underwent living-related liver transplantation at age 8 months. The wrist drop was still present at age 1 year despite hematoma resolution.ConclusionsDelayed detection of BA and inadequate prevention of VKDB can result in permanent peripheral neuropathy.

Cerebral Hemorrhage with Edema in A Five-Week-Old: A Case of Late-Onset Vitamin K Deficiency Bleeding, Rare Diagnosis in Resource-Limited Settings

Introduction: Vitamin K deficiency bleeding (VKDB) is a term that describes the condition of hemorrhagic disorders in newborns. Late-onset VKDB occurs between the second week and sixth month of life. Intracranial hemorrhage often occurs in cases of late-onset VKDB and can cause 14-20% mortality and 40% long-term neurological morbidity, so it is important to treat patients until they are stable, especially with limited health facilities. Case Report: A baby boy aged 1 month 8 days was brought by his parents to RSUD Deli Serdang Lubuk Pakam with the chief complaint of an enlarged stomach, accompanied by paleness, weakness, convulsions, and altered consciousness. A midwife assisted the delivery with unknown history of immediate vitamin K injection after birth. We diagnosed the patient with VKDB according to the clinical symptoms. The head CT scan showed subdural and subarachnoid hemorrhage with cerebral edema. We transfused the patient with Packed Red Cells and Fresh Frozen Plasma 20 cc/12 hours 5 times, administered Vitamin K injection 3 mg/IM for 3 days, and other supportive therapy. The patient's condition improved within the third day of hospitalization with recovered consciousness and was transferred to the referral hospital. Discussion: The key feature of late-onset VKDB is the incidence of ICH in 30-88% of patients, leading to a high incidence of mortality. This study highlights the importance of prompt, and early treatment of VKDB with proper history taking, clinical examination, and relevant investigations to reduce morbidity and mortality. Conclusion: In conclusion, secondary late-onset PDVC is more common than the primary subtype, and late-onset PDVC is still an important cause of morbidity and mortality in developing countries including Indonesia, where vitamin K prophylaxis is not routinely performed

SIMULTANEOUS DETERMINATION OF PHYTONADIONE AND ITS DEGRADANTS BY HPLC IN INJECTABLE EMULSION FORMULATION USED TO TREAT VKDB IN NEWBORNS

Phytonadione, also known as Phytomenadione or Vitamin K1 is used as an Injectable emulsion is used to Newborns for the precautionary treatment for Vitamin K Deficiency Bleeding (VKDB) during birth. In the current study, A Gradient, Sensitive & Cost effective HPLC method has been developed to determine and quantify the degradants of Phytonadione and Benzyl Alcohol into Phytonadione Injectable Emulsion. The chromatographic separation was performed by GL Sciences Inert sustain HP™ C18 (250 × 4.6 mm, 3.0 μ) column. The degradants were well separated by a gradient program started with the mixture of 25 mM Ammonium Acetate in water as buffer, pH 3.5 and Methanol in the ratio of 40: 60 V/V at the flow rate of 1.0 mL min­­‑1 and UV detection was performed at 254 nm. The degradation products from Phytonadione and Benzyl Alcohol were well resolved from the main peaks and its other impurities by the developed method. The method was validated by complying specificity/selectivity, linearity, limit of detection (LOD), limit of quantification (LOQ), accuracy and precision following ICH Q2 (R1). The developed method in this study could be applied for the analysis of routine quality control related substances of Phytonadione Injectable Emulsion, since there is no official monograph. KEYWORDS: Phytomenadione, Vitamin K, Method validation, Impurities, Degradants.

The Legal Limits of Parental Autonomy: Do Parents Have the Right to Refuse Intramuscular Vitamin K for Their Newborn?

Description The American Academy of Pediatrics recommends that all newborns receive an intra-muscular (IM) dose of vitamin K within 6 hours of delivery for the prevention of vitamin K deficiency bleeding (VKDB). There has been an increase in the number of parents who have refused the IM vitamin K dose for their infant based on its possible link to leukemia, preservatives that may lead to adverse reactions, and wanting to avoid pain for the infant. When newborns do not receive IM vitamin K, the most serious feared potential complication is intracranial hemorrhage with potential neurologic sequela including seizures, developmental delay, and death. Recent studies support the contention that parents are making the choice to refuse IM vitamin K without sufficient knowledge of the potential consequences. Parental decisions typically align with the best interest of the child; however, when parental decisions veer from the child's best interest, the limit of parental autonomy is tested. The precedent set by previous cases in which parental autonomy was challenged suggests parents should not be able to refuse IM vitamin K because the therapy has nearly no burden and forgoing this therapy has the potential for substantial harm. It has been argued that as long as the degree of intrusion is modest (a single IM injection) and the benefit substantial (prevention of possible death), states are granted the power to mandate the use of such an intervention. Mandated IM vitamin K for all newborns, regardless of parental approval, would rescind some parental autonomy but improve overall beneficence, nonmaleficence, and justice in the care of newborns.

Management of Bleeding due to Vitamin K Deficiency in Neonates: A Case Report

Vitamin K deficiency bleeding (VKDB) is an uncommon and life-threatening bleeding condition in infancy. This study aimed to present a case of bleeding due to vitamin K deficiency in neonates. A 7-day-old male infant presented to an emergency department (ED) following bleeding from an umbilical stump for 3 hours upon arrival at the hospital. On examination of the general condition, the patient is in good health, responsive, conscious and active tonus. Physical examination revealed there were no petechiae, purpura, or ecchymoses. On the abdomen region, there was minimal bleeding in an umbilical area with periumbilical hemorrhagic crusting. Intense palpation revealed mild tenderness near the periumbilical area. When the umbilical area was palpated deeply, a thin, watery blood fluid oozed out. The results of routine blood laboratory examinations showed within normal limits (Hb 12 g/dL, leukocytes 6.9x103/μL, and platelets 150x10³/μL). This patient was diagnosed with bleeding due to vitamin K deficiency. The management given is in the form of a subcutaneous injection of vitamin K 10 mg for 3 days. After administration of the third injection, the patient's condition improves, and the umbilical hemorrhage subsides.

Neonatologists and vitamin K hesitancy.

Hemorrhagic disease of the newborn, more aptly termed "Vitamin K Deficiency Bleeding (VKDB)," has long been recognized as a cause of significant morbidity and mortality in early infancy. A single intramuscular dose of vitamin K administered at birth has virtually eliminated VKDB, and this prophylactic regimen has been recommended by the American Academy of Pediatrics since 1961. Although most newborns in the United States receive vitamin K at birth, a growing number of parents are hesitant about this intervention, citing concerns about harm from the injection, preservatives contained in the medication, and clashes with personal belief systems. Ultimately, there is distrust in the medical establishment as many of these parents also opt out of newborn ophthalmic prophylaxis and importantly, childhood vaccinations, establishing a dangerous public health precedent that will lead to resurgence of vaccine-preventable diseases. Various shared decision making models and educational efforts can assist newborn health care professionals in addressing these parental concerns so that VKDB can be effectively prevented in all newborns.

Gastrointestinal bleeding due to idiopathic early onset of vitamin K deficiency bleeding in a girl baby 50 min after birth: a rare case

BackgroundThe incidence of early-onset vitamin K deficiency bleeding (VKDB) in at-risk neonates who did not receive vitamin K supplementation varied from 6 to 12%. This case report aims to show that VKDB can occur abruptly after birth despite vitamin K1 1 mg IM being given immediately after birth.Case presentationA term female baby was born through vaginal delivery of a 28 years old mother, G1P0A0, 39–40 weeks gestation with normal APGAR score, and birth weight was 3445 g, birth length was 52 cm. During pregnancy, the mother did not take any drugs except vitamins. There are no abnormalities on the baby’s physical examination. The anus is patent. Immediately after birth, the baby received a vitamin K1 1 mg intramuscularly. Abruptly, 50 min after delivery, there was meconium with lots of fresh blood. Laboratory results showed hemoglobin, 19.6 g/dL; leukocytes, 25,010/uL; platelets, 390,000/uL, with increased PT and aPTT. A peripheral blood smear showed a normal blood morphology. When 7 h old, the baby had much hematochezia. Laboratory results showed decreased hemoglobin to 17.5 g/dL and increased PT, aPTT, and INR. No abnormalities were found on the babygram and abdominal ultrasound. The working diagnosis was gastrointestinal bleeding due to idiopathic early-onset VKDB. The baby received vitamin K1 2 mg IM, Fresh Frozen Plasma, and a Packed Red Cells transfusion. The patient returned home in good clinical condition.ConclusionVitamin K1 1 mg IM prophylaxis should be given immediately after birth to prevent early-onset VKDB. In addition, pregnant women who receive drugs that interfere with vitamin K metabolism (anti-epileptic drugs, anti-tuberculosis drugs, vitamin K antagonist drugs) should be given prophylactic vitamin K1, 20 mg/d orally, for at least two weeks before the expected time of delivery.

Clinical profile and outcome of neonates presenting with hemorrhagic disease at a tertiary care hospital in Karachi, Pakistan.

Objective: To identify the clinical presentations and outcomes of infant with Hemorrhagic Disease of Newborn (HDN). Study Design: Descriptive Cross-sectional study. Setting: Department of Neonatology, National Institute of Child Health (NICH), Karachi, Period: July to December 2021. Material & Methods: The babies diagnosed with HDN were included in the study. Age at onset of symptoms, gender, feeding pattern, place of delivery, site of bleeding and outcome were recorded. The outcome was compared with the chi-square test and the p-value <0.05 is considered significant. Results: Ninety five babies were included in the study. Male to female ratio was 1.87:1 and mean age of admission was 6.31 ± 5.98 days. The type of HDN was Early in 21 (22.1%), Classic in 55 (57.9%) and Late in 19 (20%) babies. In this study, 77.9 % babies were on exclusive breast feeding. Fifty four (56.8%) were delivered at homes, 9 (9.5%) at private clinics and 32 (33.7%) at government hospitals. In our country most babies are delivered at home where vitamin K is not given prophylactic to the newborn, leading to HDN. The site of bleeding were gastrointestinal, superficial, umbilicus and intracranial in 36 (37.9%), 24 (25.3 %), 21 (22.1%) and 12 (12.6%) neonates respectively. In this study, majority of babies (88.4 %) discharged. Conclusion: HDN was common in male gender, home deliveries, vaginal deliveries and breast fed.

Physicians' Opinion and Practice of Vitamin K Administration at Birth in Romania.

(1) Background. Vitamin K is recommended worldwide as a standard of care for the prophylaxis of vitamin-K-deficiency bleeding (VKDB). This is also a standard practice in Romania, but due to the rising number of refusals by parents of basic interventions in the neonatal period, we aimed to assess the Romanian neonatologists’ opinions and current practice regarding vitamin K administration at birth. (2) Methods. We designed and conducted an electronic survey addressed to 110 physicians working in Romanian hospitals. (3) Results. Half of respondents are accustomed to receiving refusals for vitamin K administration once or twice a year. When parents refuse vitamin K administration, they usually refuse other neonatal interventions, according to 90.9% of the responding physicians, and this situation has occurred more frequently during the last two years. The number of refusals and especially their increase are more frequent in level III hospitals (p = 0.0304, p = 0.0036, respectively). Only 22.7% of the physicians responded that they would recommend an oral preparation of vitamin K in the absence of intramuscular prophylaxis. (4) Conclusion. Efforts should be made to address parents’ concerns and to have available alternatives to the intramuscular administration of vitamin K.

Vitamin K and the Newborn Infant.

Intramuscular administration of vitamin K for prevention of vitamin K deficiency bleeding (VKDB) has been a standard of care since the American Academy of Pediatrics recommended it in 1961. Despite the success of prevention of VKDB with vitamin K administration, the incidence of VKDB appears to be on the rise. This increase in incidence of VKDB is attributable to parental refusal as well as lowered efficacy of alternate methods of administration. The aim of this statement is to discuss the current knowledge of prevention of VKDB with respect to the term and preterm infant and address parental concerns regarding vitamin K administration.

Outcomes and Disease Spectrum of LBW Neonates in a Secondary Health Facility.

Globally, 30 million low birth weight (LBW) babies are born every year and 95% of them are from developing countries. LBW neonates are at a high risk of mortality, morbidity, and long-term disability. The objective of this study is to investigate outcomes and disease spectrum among low birth weight neonates. This is a prospective, observational study conducted on 540 neonates admitted in the Mother and Child Hospital, Akure, Ondo State, Nigeria, from 2017 to 2018. Questionnaire, interview, clinical, and diagnostic procedures were used as research tools. There were 137 low birth weight (LBW) neonates, with the mean mothers' age of 31.92 ± 6.60. Of the 540 neonates, 69 (50.4%) and 68 (49.6%) were term and preterm, respectively. There were 64 female neonates (46.7%) and 73 male neonates (53.3%). The mean weight of the neonates was 1.82 ± 0.44 kg, and mean number of days on admission was 6.42 ± 6.75 days. Neonatal sepsis (NNS) was the highest morbidity 51 (37.2%) among the LBW neonates, followed by prematurity 47 (34.4%) and neonatal jaundice (NNJ) 18 (13.1%). Sex (χ2 = 3.584, p=0.310), mode of delivery (χ2 = 4.669, p=0.198), and gestational age (χ2 = 3.904, p=0.272) were not a significant determinant of outcome among LBW neonates. Men were 2.36 times more likely to be preterm (OR = 2.36, 95% CL = 1.01–5.54, p=0.048) among LBW neonates. Outcomes of LBW neonates who were delivered by SVD were not significant compared to preterm delivered by CS (OR = 0.46, 95% CL = 0.13–1.65, p=0.096). Sixty percent (60%) of the mothers had Prolonged Rupture of Membranes (PROM). Morbidities such as hypothermia (72.2%), apnoea (63.6%), haemorrhagic disease of the newborn (HDN) (66.7%), and respiratory distress syndrome (RDS) (66.7%) were more observed with preterm LBW neonates. Importance of qualitative antenatal care (ANC) should be emphasized; anticipation and prevention of LBW births can help mitigate some of the problems they are prone to.

К вопросу о роли возможного синдрома мальабсорбции жиров при грудном вскармливании в развитии поздней геморрагической болезни новорожденного

The causes of late hemorrhagic disease of the newborn (HDN) are parenteral nutrition, severe diseases (e.g., biliary atresia, congenital or inherited diseases associated with cholestasis, short bowel syndrome), exclusive breastfeeding, and digestive disorders with malabsorption. Meanwhile, vitamin K deficiency develops in severe malabsorption and digestive disorders resulting from an irrational diet of a nursing mother or viral infections with the intestinal syndrome. Lipidogram of feces was evaluated by thin-layer chromatography in 15 children with late HDN. Lipidogram demonstrated high lipid content (on average, 77.47 μg/g). Moreover, the maximum levels of higher fatty acids, cholesterol, and phospholipids were detected in children with the most severe clinical presentations of bleeding. Clinical manifestations of hemorrhagic syndrome included umbilical cord bleeding (66.7%), gastrointestinal bleeding (28.5%), and intracranial hemorrhage (6.7%). In addition, all children have one or more clinical symptoms of digestive disorders (i.e., frequent bowel movements, excessive pooping, watery diarrhea). Occasionally, bloody streaks were reported. Education of nursing mothers to plan their diet and follow a balanced diet demonstrates that strict adherence to these recommendations significantly reduces the risks of vitamin K deficiency in newborns and late HDN. KEYWORDS: vitamin K, vitamin K deficiency bleeding, breastfeeding, children, lipidogram of feces, late hemorrhagic disease of the newborn, malabsorption. FOR CITATION: Mozzhukhina L.I., Kalgina S.E., Stroeva L.E., Teyf V.A. Role of fat malabsorption during breastfeeding in late hemorrhagic disease of the newborn. Russian Journal of Woman and Child Health. 2022;5(1):85–89 (in Russ.). DOI: 10.32364/2618- 8430-2022-5-1-85-89

A Case of Late-Onset Vitamin K Deficiency Bleeding in an Exclusively Breastfed Infant Emphasizing the Need for Revision of Vitamin K Prophylaxis Policy

A 4-month-old male child presented with a history of seizure and vomiting. There was no history of fever, fall, or any other trauma. On examination, there was anisocoria, and anterior fontanelle was bulging and nonpulsating. Computerized tomography revealed an acute on chronic bilateral subdural hematoma (left > right) with a midline shift. He had no relevant past or family history suggestive of any bleeding disorder. Blood investigations revealed anemia with prolonged prothrombin time (PT)/international normalized ratio/and activated partial thromboplastin time (APTT). Mixing study was done and it showed a correction with pooled normal plasma. The possibility of coagulation factor deficiency was confirmed. Further, mixing studies and factor assays revealed normal levels of fibrinogen and Factor VIII, with a reduced level of Factor IX. Since both PT and APTT were prolonged and Factor IX level was low, a deficiency of Vitamin K-dependent coagulation factors was suspected. The child was immediately given intravenous Vitamin K injection. The diagnosis of Vitamin K deficiency bleeding (VKDB) was confirmed by protein induced by Vitamin K absence testing. Unfortunately, the child succumbed to the complications of the intracranial bleed.

Belgian Consensus Recommendations to Prevent Vitamin K Deficiency Bleeding in the Term and Preterm Infant.

Neonatal vitamin K prophylaxis is essential to prevent vitamin K deficiency bleeding (VKDB) with a clear benefit compared to placebo. Various routes (intramuscular (IM), oral, intravenous (IV)) and dosing regimens were explored. A literature review was conducted to compare vitamin K regimens on VKDB incidence. Simultaneously, information on practices was collected from Belgian pediatric and neonatal departments. Based on the review and these practices, a consensus was developed and voted on by all co-authors and heads of pediatric departments. Today, practices vary. In line with literature, the advised prophylactic regimen is 1 or 2 mg IM vitamin K once at birth. In the case of parental refusal, healthcare providers should inform parents of the slightly inferior alternative (2 mg oral vitamin K at birth, followed by 1 or 2 mg oral weekly for 3 months when breastfed). We recommend 1 mg IM in preterm <32 weeks, and the same alternative in the case of parental refusal. When IM is perceived impossible in preterm <32 weeks, 0.5 mg IV once is recommended, with a single additional IM 1 mg dose when IV lipids are discontinued. This recommendation is a step towards harmonizing vitamin K prophylaxis in all newborns.

Case 1: A Term Neonate with Conjunctival Hemorrhage, Ecchymoses, and Umbilical Hematoma

A term male neonate with a birthweight of 3,350 g is born via emergency cesarean delivery for the indication of abruptio placenta. The mother is a booked and immunized, gravida 4, para 3 woman with normal platelet counts and an uneventful antenatal course. The neonate was conceived spontaneously in a nonconsanguineous marriage and the family history is nonsignificant. The neonate has a normal transition after birth, is given a 1-mg intramuscular injection of vitamin K in the right thigh; he rooms in with the mother and is exclusively breastfed. Around 48 hours after birth, the neonate is noted to have bilateral conjunctival hemorrhages, ecchymoses on the face and trunk/back, boggy swelling over the scalp, and umbilical cord hematoma (Figs 1, 2 and 3). The neonate is noted to have pallor, but his vital sign parameters are normal (heart rate 140 beats/min, respiratory rate 40 breaths/min, temperature 98.6oF [37oC], capillary refill time <2 seconds, and oxygen saturation 96% in room air). There is no history of hematemesis, hematuria, or bleeding per rectum. Figure 1. Conjunctival hemorrhage. Figure 2. Ecchymoses on the face. Figure 3. Umbilical hematoma. ### Progression With a provisional clinical diagnosis of vitamin K deficiency bleeding (VKDB), the neonate is given a repeat 1-mg intramuscular injection of vitamin K and evaluated for the cause of the bleeding manifestations. Laboratory investigations reveal a hemoglobin of 6.4 …

Pediatric Emergency Medicine Simulation Curriculum: Vitamin K Deficiency in the Newborn.

IntroductionThe American Academy of Pediatrics recommends vitamin K prophylaxis at birth for all newborns to prevent vitamin K deficiency bleeding (VKDB). Despite a lack of evidence for serious harms, barriers to prophylaxis, including parental refusal, are rising, as are cases of VKDB.MethodsThis simulation involved an infant presenting to the emergency department who decompensated due to a cerebral hemorrhage caused by VKDB and was treated by pediatric and emergency providers. The case was incorporated into the fellow and division monthly curricula, and participants completed postsimulation surveys. The patient required a secure airway, seizure management, vitamin K, and a fresh frozen plasma infusion upon suspicion of the diagnosis, plus a coordinated transfer to definitive care. The case included a description of the simulated case, learning objectives, instructor notes, an example of the ideal flow of the scenario, anticipated management mistakes, and educational materials.ResultsThe simulations were carried out with 48 total participants, including 40 fellows and eight attendings, from five different training institutions over 1 year. In surveys, respondents gave overall positive feedback. Ninety-four percent of participants gave the highest score on a Likert scale indicating that the simulation was relevant, and over 80% gave the highest score indicating that the experience helped them with medical management.DiscussionThis simulation trained physicians how to recognize and treat a distressed infant with VKDB. The case was perceived to be an effective learning tool for both fellow and attending physicians.

Vitamin K Deficiency Bleeding: An Ounce of Prevention.

Vitamin K is a fat-soluble vitamin essential for the formation of factors in the clotting cascade. Newborns are born with insufficient levels of vitamin K, resulting in high risk for vitamin K deficiency bleeding (VKDB). Vitamin K deficiency bleeding can occur in the first week of life ("classic" VKDB) and also between 2 weeks and 3 months of age ("late" VKDB). Vitamin K deficiency bleeding can present as bleeding in the skin or gastrointestinal tract, with as many as half of affected neonates experiencing intracranial bleeding. A single intramuscular injection of vitamin K effectively prevents both classic and late VKDB. Although intramuscular vitamin K is safe and effective, VKDB has reemerged because of decreased utilization. Parents refuse intramuscular vitamin K for a variety of reasons, including a disproven association with childhood cancer, the desire to avoid exposure to additives, and valid concerns about early neonatal pain. Many parents request oral vitamin K, an inferior alternative strategy that requires multiple doses utilizing products not designed for neonatal oral administration. In this setting, health care professionals must understand the epidemiology of VKDB and compassionately counsel parents to assuage concerns. Delivery of intramuscular vitamin K to all newborns remains a public health imperative, benefitting thousands of infants annually.

The challenge to define the optimal prophylactic regimen for vitamin K deficiency bleeding in infants.

Infants are at risk of vitamin K deficiency that may lead to vitamin K deficiency bleeding (VKDB). Although many vitamin K prophylactic regimens have been developed throughout the years, still cases of late form VKBD may occur. The introduction of combined prophylactic strategy with prolonged oral prophylaxes after the intramuscular dose at birth has showed a decrease of the late severe VKDB incidence. Nevertheless, there is still lack of consensus about the administration scheme after the first dose at birth. CONCLUSION: Late form VKBD is not eradicated, and the best prophylactic regimen in term and preterm infants is still an open debate.