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Prevention of Vitamin K Deficiency Bleeding in Newborn Infants: a Position Paper by the ESPGHAN Committee on Nutrition

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Prevention of Vitamin K Deficiency Bleeding in Newborn Infants: a Position Paper by the ESPGHAN Committee on Nutrition Zurich Open Repository and Archive University of Zurich Main Library Strickhofstrasse 39 CH-8057 Zurich www.zora.uzh.ch Year: 2016 Prevention of vitamin K deficiency bleeding in newborn infants: a position paper by the ESPGHAN committee on nutrition Mihatsch, Walter A ; Braegger, Christian ; Bronsky, Jiri ; Campoy, Cristina ; Domellöf, Magnus ; Fewtrell, Mary ; Mis, Nataša F ; Hojsak, Iva ; Hulst, Jessie ; Indrio, Flavia ; Lapillonne, Alexandre ; Mlgaard, Christian ; Embleton, Nicholas ; van Goudoever, Johannes ; ESPGHAN Committee on Nutrition Abstract: Vitamin K deficiency bleeding (VKDB) due to physiologically low vitamin K plasma concen- trations is a serious risk for newborn and young infants and can be largely prevented by adequate vitamin K supplementation. The aim of this position paper is to define the condition, describe the prevalence, discuss current prophylaxis practices and outcomes, and to provide recommendations for the prevention of VKDB in healthy term newborns and infants. All newborn infants should receive vitamin K prophy- laxis and the date, dose, and mode of administration should be documented. Parental refusal of vitamin K prophylaxis after adequate information is provided should be recorded especially because of the risk of late VKDB. Healthy newborn infants should either receive 1 mg of vitamin K1 by intramuscular injection at birth; or 3 × 2 mg vitamin K1 orally at birth, at 4 to 6 days and at 4 to 6 weeks; or 2 mg vitamin K1 orally at birth, and a weekly dose of 1 mg orally for 3 months. Intramuscular application is the preferred route for efficiency and reliability of administration. The success of an oral policy depends oncompliance with the protocol and this may vary between populations and healthcare settings. If the infant vomits or regurgitates the formulation within 1 hour of administration, repeating the oral dose may be appro- priate. The oral route is not appropriate for preterm infants and for newborns who have cholestasis or impaired intestinal absorption or are too unwell to take oral vitamin K1, or those whose mothers have taken medications that interfere with vitamin K metabolism. Parents who receive prenatal education about the importance of vitamin K prophylaxis may be more likely to comply with local procedures. DOI: https://doi.org/10.1097/MPG.0000000000001232 Posted at the Zurich Open Repository and Archive, University of Zurich ZORA URL: https://doi.org/10.5167/uzh-134095 Journal Article Published Version Originally published at: Mihatsch, Walter A; Braegger, Christian; Bronsky, Jiri; Campoy, Cristina; Domellöf, Magnus; Fewtrell, Mary; Mis, Nataša F; Hojsak, Iva; Hulst, Jessie; Indrio, Flavia; Lapillonne, Alexandre; Mlgaard, Chris- tian; Embleton, Nicholas; van Goudoever, Johannes; ESPGHAN Committee on Nutrition (2016). Preven- tion of vitamin K deficiency bleeding in newborn infants: a position paper by the ESPGHAN committee on nutrition. Journal of Pediatric Gastroenterology and Nutrition, 63(1):123-129. DOI: https://doi.org/10.1097/MPG.0000000000001232 SOCIETY PAPER Prevention of Vitamin K Deficiency Bleeding in Newborn Infants: A Position Paper by the ESPGHAN Committee on Nutrition ÃWalter A. Mihatsch, yChristian Braegger, zJiri Bronsky, §Cristina Campoy, jjMagnus Domello¨f, ôMary Fewtrell, #Natasˇa F. Mis, ÃÃIva Hojsak, yyJessie Hulst, zzFlavia Indrio, §§jjjjAlexandre Lapillonne, ôô##Christian Mølgaard, ÃÃÃNicholas Embleton, and yyyzzzJohannes van Goudoever, ESPGHAN Committee on Nutrition ABSTRACT for 3 months. Intramuscular application is the preferred route for efficiency Vitamin K deficiency bleeding (VKDB) due to physiologically low vitamin and reliability of administration. The success of an oral policy depends on K plasma concentrations is a serious risk for newborn and young infants and compliance with the protocol and this may vary between populations and can be largely prevented by adequate vitamin K supplementation. The aim of healthcare settings. If the infant vomits or regurgitates the formulation this position paper is to define the condition, describe the prevalence, discuss within 1 hour of administration, repeating the oral dose may be appropriate. current prophylaxis practices and outcomes, and to provide recommen- The oral route is not appropriate for preterm infants and for newborns who dations for the prevention of VKDB in healthy term newborns and infants. have cholestasis or impaired intestinal absorption or are too unwell to take All newborn infants should receive vitamin K prophylaxis and the date, dose, oral vitamin K , or those whose mothers have taken medications that and mode of administration should be documented. Parental refusal of 1 interfere with vitamin K metabolism. Parents who receive prenatal education vitamin K prophylaxis after adequate information is provided should be about the importance of vitamin K prophylaxis may be more likely to recorded especially because of the risk of late VKDB. Healthy newborn comply with local procedures. infants should either receive 1 mg of vitamin K1 by intramuscular injection at birth; or 3  2 mg vitamin K1 orally at birth, at 4 to 6 days and at 4 to 6 Key Words: newborn infant, vitamin K, vitamin K deficiency bleeding weeks; or 2 mg vitamin K1 orally at birth, and a weekly dose of 1 mg orally (JPGN 2016;63: 123–129) Received March 30, 2016; accepted March 31, 2016. From the ÃDepartment of Pediatrics, Harlaching, Munich Municipal ealthy newborns and infants are at risk of developing severe Hospitals, Munich, Germany, the yDepartment of Pediatric Gastroenter- H hemorrhages and especially intracranial hemorrhages due to ology, University Children’s Hospital, Zurich, Switzerland, the physiologically low concentrations of vitamin K that result in low zDepartment Pediatrics, University Hospital Motol, Prague, Czech concentrations of vitamin K–dependent clotting factors. Therefore Republic, the §Department of Pediatrics, University of Granada, Gran- prophylaxis against vitamin K deficiency bleeding (VKDB) ada, Spain, the jjDepartment of Clinical Sciences, Pediatrics, Umea˚ is important. University, Umea˚, Sweden, the ôChildhood Nutrition Research Centre, # The aim of this position paper is to define the condition, UCL Institute of Child Health, London, UK, the Department of describe the prevalence, discuss current prophylaxis practices and Gastroenterology, Hepatology and Nutrition, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia, outcomes, and to provide recommendations for setting up local the ÃÃUniversity Children’s Hospital Zagreb, Zagreb, Croatia, the guidelines for the prevention of VKDB in newborns and infants. yyDepartment of Pediatrics, Erasmus Medical Center, Sophia Children’s Hospital, Rotterdam, The Netherlands, the zzDepartment of Pediatrics, University Hospital Giovanni XXIII, University Aldo Moro, Bari, Italy, HISTORY OF HEMORRHAGIC DISEASE the §§APHP Necker-Enfants Malades Hospital, Paris Descartes Univer- OF THE NEWBORN sity, Paris, France, the jjjjCNRC, Baylor College of Medicine, Houston, TX, the ôôDepartment of Nutrition, Exercise and Sports, University of Hemorrhagic disease of the newborn (1) was first system- Copenhagen, København, the ##Hans Christian Andersen Children’s atically described by Charles Townsend in 1894 (2). He described Hospital, Odense University Hospital, Odense, Denmark, the 50 cases of a bleeding disorder that occurred in 0.6% of newborn ÃÃÃNewcastle Neonatal Service, Newcastle Hospitals NHS Foundation infants usually on days 2 to 3. This is nowadays classified as the Trust, Newcastle upon Tyne, UK, the yyyDepartment of Pediatrics, VU classic form of VKDB and mainly affects the skin, gastrointestinal University Medical Center, and the zzzDepartment of Pediatrics, Emma tract, and brain. The case fatality rate was 62%, whereas surviving Children’s Hospital-AMC, Amsterdam, The Netherlands. infants typically recovered within 5 days. At that time it was, Address correspondence and reprint requests to Walter A. Mihatsch, MD, however, impossible to differentiate sepsis-induced bleeding PhD, Department of Pediatrics Harlaching, Munich Municipal Hospital disorders such as disseminated intravascular coagulation from Group, Sanatoriumsplatz 2, 81545 Munich, Germany (e-mail: [email protected];[email protected]). VKDB. The average incidence in unsupplemented populations The authors report no conflicts of interest. has been estimated to be 0.25% to 1.7% (3) based on reported Copyright # 2016 by European Society for Pediatric Gastroenterology, incidences of 0.25% (4), 0.33% (5) up to 13.9% (6) in a single study Hepatology, and Nutrition and North American Society for Pediatric (also including hemorrhages of the circumcision wound). Gastroenterology, Hepatology, and Nutrition The underlying pathophysiology was first described by the DOI: 10.1097/MPG.0000000000001232 biochemist Henrik Dam. In 1929 he discovered a ‘‘Coagulation’’ JPGN Volume 63, Number 1, July 2016 123 Copyright © ESPGHAL and NASPGHAN. All rights reserved. Mihatsch et al JPGN Volume 63, Number 1, July 2016 factor in chicken (coagulations vitamin, vitamin K) (7). Sub- (2) Multiple menaquinones (vitamin K2), synthesized by bacteria sequently, prothrombin deficiency was documented in newborns such as intestinal bacteria and found in egg yolk, chicken, beef, with VKDB by Brinkhous et al (8) and Dam et al (9–15). Waddell liver, fermented products such as cheese, and in fermented et al (16) showed that vitamin K prevents hemorrhagic disease of vegetables
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