I am especially frustrated when parents refuse to give their newborns vitamin K after birth. Since 1961, the American Academy of Pediatrics has recommended giving every newborn a single shot of vitamin K given at birth. This is a life saving treatment to prevent bleeding. Life saving.
Vitamin K works to help our blood clot. Insufficient levels can lead to bleeding in the brain or other vital organs. Vitamin K deficiency bleeding or VKDB, can occur any time in the first 6 months of life. There are three types of VKDB, based on the age of the baby when the bleeding problems start: early, classical and late. Unfortunately there are usually no warning signs that a baby will have significant bleeding, so when the bleeding happens, it's too late to do anything about it. Why parents don't want to give this preventative life saving treatment is usually based on incorrect information.
This is a matter of a fairly low risk of bleeding if you don't give vitamin K: 250-1700 per 100,000 within the first week, and 4-7 per 100,000 between 2 and 12 weeks. You might notice that the number is variable - it's hard to study since the large majority of babies have gotten vitamin K over the years and the risk is low even without vitamin K. However, when there is bleeding it has significant consequences: lifelong disability or death. And we also know that there's very low risk from the vitamin K and it works very well to prevent bleeding. So why take the chance of not giving it?
Conspiracy Theories, Misunderstandings, and Science
This is not a governmental conspiracy to somehow kill children. It's a world wide attempt to help children survive and thrive. The World Health Organization (WHO) guidelines:
- All newborns should be given 1 mg of vitamin K intramuscularly [IM] after birth [after the first hour during which the infant should be in skin-to-skin contact with the mother and breastfeeding should be initiated]. (Strong recommendation, moderate quality evidence)
Most people look at scientific information and can't make heads or tails of what it means.
|Photo Source: Hemorrhagic Disease of the Newborn|
I'm going to attempt to de-bunk the most common concerns I've heard because the best way to combat misinformation is to help explain the facts as we know them.
1. If every baby's born with too little vitamin K, that's the way we're supposed to be.
Babies are born with very little vitamin K in their body. If they don't get it with a shot, they need to either eat it or make it. Breast milk has very little vitamin K and babies won't be eating leafy greens for quite awhile. Formula does have it, but it takes several days for vitamin K to rise to protective levels with formula and the highest risk of bleeding is during that first week of life. (Of course if you're using this argument because you want babies to be all natural, you probably won't be giving formula at this point.)
Bacteria help us make vitamin K, but babies aren't colonized at birth with these gut bacteria.
Just because they're born that way doesn't mean they're supposed to stay that way. Inside the mother the baby is in a very different situation. They don't breathe air. They don't eat. They don't have gut bacteria. Their heart has a bypass tract to avoid pumping blood to the lungs. This all works well in utero, but must change once they leave the womb. Change takes time, and during this time they are at risk. Why not minimize the risk if we know a safe way to do it?
2. The package insert has a big warning at the top that it can kill.
There are many reasons why we should not use the package insert of a medicine or vaccine to make healthcare decisions. These have been discussed before so I won't go into all the details but please see these great blogs on how to read and use package inserts:
It is true that there is a black box warning on the top of the vitamin K package insert. This has scared some parents from wanting to get the vitamin K shot for their newborn.
|Screen Shot from Package Insert|
Reactions to IV (intravenous) vitamin K are much more common than IM (intramuscular) injections. The difference is anything given by IV goes directly into the bloodstream and back to the heart. But we don't give vitamin K by IV to newborns.
IM injections go into the muscle, allowing very slow absorption of the medicine. This not only decreases reactions to the injected vitamin, but also helps the level of vitamin K stay elevated for a prolonged time after a single injection.
I only found one report of a newborn with a significant reaction to vitamin K. The authors of the paper did note that IM vitamin K has been given for many years to babies all over the world without significant reactions and could not explain why the one infant had such a significant reaction.
Since we must always look at risk vs benefit, the very, very low risk of a serious reaction from receiving vitamin K IM is preferable to the benefit of the prevention of VKDB.
Another great resource on this topic is Dr. Vincent Iannelli's That Black Box Warning on Vitamin K Shots.
3. Vitamin K causes cancer.
Many years ago there was a small study that suggested vitamin K led to childhood cancers. This issue has been extensively studied since then and no link has been found.
Vitamin K does not cause cancer.
Rates of cancer have not increased in the years since vitamin K has been given to the large majority of newborns worldwide. This is reported in the Vitamin K Ad Hoc Task Force of the American Academy of Pediatrics report Controversies Concerning Vitamin K and the Newborn.
4. Bleeding from vitamin K deficiency is rare or mild.
In the US bleeding from vitamin K deficiency is rare because most babies get the vitamin K shot soon after birth. In countries where vitamin K is not used routinely, bleeding is not rare at all. Some communities of the US where vitamin K is being refused by parents are seeing an increase in newborn bleeding.
Early VKDB occurs within 24 hours of birth and is almost exclusively seen in infants of mothers taking drugs which inhibit vitamin K. These drugs include anticonvulsants, anti-tuberculosis drugs, some antibiotics (cephalosporins) and blood thinners to prevent clots. Early VKDB is typically severe bleeding in the brain or gut.
Classic VKDB typically occurs during the first week of life. The incidence of classic VKDB ranges from 0.25-1.7 cases per 100 births.
Late onset VKDB occurs between 2 and 12 weeks usually, but is possible up to 6 months after birth. Late VKDB has fallen from 4.4-7.2 cases per 100,000 births to 1.4-6.4 cases per 100,000 births in reports from Asia and Europe after routine prophylaxis was started.
One out of five babies with VKDB dies. Of the infants who have late VKDB, about half have bleeding into their brains, which can lead to permanent brain damage if they survive. Others bleed in their stomach or intestines, or other vital organs. Many need blood transfusions or surgeries to help correct the problems from the bleeding.
5. It's just as good to use oral vitamin K.
Early onset VKDB is prevented well with the oral vitamin K in countries that have oral vitamin K available, but late onset VKDB is an issue. Children with liver or gall bladder problems will not absorb oral vitamin K well. These problems might be undiagnosed early in life, putting these kids at risk for VKDB if they are on an oral vitamin K regimen.
There is no liquid form of vitamin K that is proven to be effective for babies in the US. That is a huge issue. Some families will order vitamin K online, but it's not guaranteed to be safe or even what it claims to be. This is an unregulated industry. It is possible to use the vitamin K solution that is typically given intramuscularly by mouth, but this requires a prescription and the taste is questionable, so baby might not take the full dose. It would be an off-label use so physicians might not feel comfortable writing a prescription. The other issue that might worry physicians is with compliance in remembering to give the oral vitamin K as directed, since most studies include babies with late onset bleeding who had missed doses.
Most of us get vitamin K from gut bacteria and eating leafy green vegetables. Newborns don't have the gut bacteria established yet so they won't make any vitamin K themselves. They may get vitamin K through their diet, but breastmilk is very low in vitamin K, so unless baby is getting formula, they will not get enough vitamin K without a supplement. It is possible for mothers who breastfeed to increase their vitamin K intake to increase the amount in breast milk, but not to sufficient levels to protect the baby without additional vitamin K.
Many countries that have used an oral vitamin K protocol, such as Denmark and Holland, have changed to an intramuscular regimen because the oral vitamin K that was previously used became no longer available.
There are various oral vitamin K dosing strategies that can be reviewed in the linked abstract. In short:
- Australia and Germany: 3 oral doses of 1 mg vitamin K are less effective than a single IM vitamin K dose. (In 1994 Australia changed to a single IM dose and their rate went to zero after the change.)
- Netherlands: A 1mg oral dose after birth followed by a daily oral dose of 25 mcg vitamin K1may be as effective as parenteral vitamin K prophylaxis.
- Sweden: (a later study) 2 mg of mixed micellar VK given orally at birth, 4 days, and 1 month has a failure rate of one case of early and four cases of late VKDB out of 458,184 babies. Of the failures, 4 had an undiagnosed liver issue, one baby's parents forgot the last dose.
When vitamin K is given IM, the chance of late VKDB is near zero. Oral vitamin K simply doesn't prevent both early and late bleeding as well -- especially if there is an unknown malabsorption disorder, regardless of which dosing regimen is used.
6. My baby's birth was not traumatic, so he doesn't need the vitamin K.
Birth trauma can certainly lead to bleeding, but the absence of trauma does not exclude it. Late vitamin K deficient bleeding (VKDB) cannot be explained by any birth traumas since they can occur months later.
7. We're delaying cord clamping to help prevent anemia and bleeding. Isn't that enough?
Delayed cord clamping can have benefits, but decreasing the risk of bleeding is not one of them. There is very little vitamin K in the placenta or newborn, so delaying the cord clamping cannot allow more vitamin K into the baby.
Still not convinced?
Read stories about babies whose parents chose to not give vitamin K: