Pros & cons of Vitamin K

I have notice a few how do not wish for baby to be given the Vitamin K inj after birth.
Why is this? from what I have read on the net there doesn't seeem to be any risk. Am I just looking in the wrong places?
So whats the pros & cons of giving Vitamin K?

I think one of the biggest cons is giving bub an injection immediately after birth, just that it may not be necessary to jab them so soon after..... Or at least that's what I thought!

Fiona I'm doing the oral Vitamen K. Because we have made the decision that its worth having, but not done via injection.

Oh ok, so is just the idea of bubs getting a needle soon after birth? Can they not give it a bit later?

I think the blood clotting thing doesn't happen naturally until bub is 8 days old (hence in the old days waiting until the 8th day to circumcise!) so you could maybe request a day or 2?

We had the injection, I had no qualms about bub getting jabbed (horrible aren't I). What's a little jab when you've just been squeezed through a birth canal? hehehe.

You can boost your diet by taking a vitamin k supplement prior to birth...

Here is a long discussion amongst UK midwives on the topic:

General issues re Vitamin K administration
I am an independent midwife working in the UK.

Policy throughout all UK health authorities (NHS) is to give routine I/M (intramuscular) dose of vit K in the first hour following delivery. If the parents refuse I/M, then 3 x oral dose is recommended.

I start my discussion of the issue with women by giving them the NHS party line as above, and explain what HDN (haemorrhagic disease of the newborn) is, and which babies are most at risk.

I then talk about the fact that globally all babies are born with low levels of vit K, and all breastfeeding women have low levels of vit K in breastmilk during the early postnatal period. Now why? Is there perhaps a protective mechanism at work which we have not yet found out about? I give out a photocopied article about this (Slattery J. British Journal of Obstetrics and Gynaecology, vol 103, no 5, May 1996, pp400-401). I also give out a useful little article in dialogue form giving the risk statistics and the question of possible association with childhood cancer in easily understandable form (Sally Yarnley. MIDIRS Midwifery Digest, Sep 1992, 2:3, p363). I also give out a more recent update on the arguments and most recent research (New Generation Digest, June 1998, pp12-13).

I always talk about how individual and difficult the decision may be for each couple, and the importance of reaching agreement between them about it. I usually link it with the immunisation issue - if the couple don't want the baby immunised, they probably will decide they don't want vit K either, on similar grounds of meddling with immature systems which we do not fully understand.

At the next visit the couple will hopefully have read and discussed the papers and reached their decision. I will support that decision whatever it is.

If following birth there are circumstances which suggest that vit K administration might be sensible I will discuss this with the couple there and then. Even if they had decided not to give it, I have never known a situation where the couple continued to refuse if there was an indication that giving it would be a good idea.

Melanie


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>Policy throughout all UK health authorities (NHS) is to give routine I/M >dose of vit K in the first hour following delivery. If the parents refuse >I/M, then 3 x oral dose is recommended.>

Actually at the NHS unit where I work policy is to *offer* 3 oral doses, and there are no specific guidelines as to when the 1st dose should be given. I tend (and I am not alone in this) to give it after the first feed, as it seems illogical to give it on a sterile gut.

>I then talk about the fact that globally all babies are born with low levels >of vit K, and all breastfeeding women have low levels of vit K in breastmilk >during the early postnatal period.>

To be pedantic, I would say that babies are born with *less* Vitamin K than adults, rather than low levels of Vitamin K. Babies are different. The parameters of normality are different in many respects between adults and neonates. Babies are a hell of a lot shorter than adults but no-one interprets that as pathological, do they?

Sara


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That's not pedantic - that's correct use of language!

We do have to be careful, and using words like 'low' and 'high' presuppose a different and contrasting norm - and of course it's the 'low' levels of Vit K in the newborn that are the norm themselves.

It's rather similar to the way breastmilk and breastfeeding are said to confer health benefits - whereas it's actually more correct to talk about 'health risks' of formula feeding.

I confess, however, that I am careful about the context I am in, and who I am talking to, when discussing the 'health risks' of formula.

Heather (breastfeeding counsellor)


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I have been asked what UK hospitals do about antibiotic eye drops and Vitamin K. Both these are administered routinely within an hour of birth in the US.

I replied that as far as I know eye drops are never given routinely, and while Vit K is given routinely with parents permission, this is never done straight after birth. Am I right?


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"In the US, the American Academy of Pediatrics and the American College of Obstetrics and Gynecology together have established the practices which I previously described as "standard of care." This is despite the fact that there is no data to back-up the time limit (1 hour). ..What do your pediatricians, neonatologists say? Is there a national policy with respect to vitamin K administration? If the US and Canada are the only ones doing it this way, then I would want to eventually work on changing it."


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Our pediatricians say as long as the baby gets Konakion within 6 hours, it is OK, so I don't feel that hurried. I know many of my colleagues use the injection to get the baby to cry vigorously (!) but that isn't my style. At all. I have no idea how the peds. arrived at the 6 hour limit either. It varies from hospital to hospital here. HDN (haemorrhagic disease of the newborn) is something most of us have never seen, as it is almost nonexistent here.

Vitamin K prophylaxis is meant to prevent hemorrhagic disease of the newborn, which doesn't manifest itself normally in the first day of life, but rather after many days or even weeks. Seems logical to me that the injection could be delayed beyond the first hour after birth. But most people seem to think it gives a baby some magical protection against bleeding from whatever trauma we may have inflicted on it during birth. If this is what is guiding practice, I would suggest that there are many other aspects of that practice which are ripe for evaluation-- if not overripe to the point of rottenness!

Rachel, Norway


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In my unit all women are given an information sheet about the pros and cons of oral and IM Vit K during the antenatal period (the Trust recommends the use of IM Vit K.) If the parents choose to have Vit K, the 1st dose is usually given in the delivery room. Consent must be given. For oral Vit K, a further 1 or 2 doses (depending on method of feeding) at weekly intervals is given.

Janet


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Vitamn K in my unit is given pretty quickly after birth. In my little tray beside the delivery pack is two syringes already prepared - one has syntometrine for third stage and the other has vitamin K for the baby. Pretty much as sooon as the placenta is delivered we 'see to' the baby -give it a midwives newborn examination and vitamin K injection. I would say in nearly all cases vitamin K is given within an hour of birth. However I have not been to the unit since it gained baby friendly status so maybe practice has changed a little.

Gillian


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I am at St Thomas's, London, and there too our policy is to give oral vit. K (although after an instrumental delivery they strongly reccomend IM)


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NHS vitamin K policy varies from Trust to Trust. In Nottingham community and at the maternity unit, intramuscular vitamin K is offered in three lots of oral dose of 0.5mg in 1ml after birth within 24 hours, at 7 days and at 28 days to all nursing babies. Breast milk substitute-fed babies only receive one oral dose after birth. Sometimes some women request intramuscular vit K for term babies(I know of two cases where both mothers were neo-natal nurses). Premature babies are given intramuscular vit k. The 0.5mg in 1ml intramuscular dose is not licensed for oral use so the paed or G.P. has to cover the prescription. I know there is a licensed 2mg oral dose but we do not use this.

I discuss the issue with the parents (but usually the mother) about why vitamin K was introduced in relation to haemorrhagic disease of the newborn. I explain that it is a very rare condition - about 1:10000 term neonates in which bleeding that could lead to the baby's demise occurs. I discuss why the I.M. vit k locally is not offered as an injection due to that one off piece of research about the childhood link to leukaemia.

It is explained that some women who plan to nurse their babies take vitamin k supplements a few weeks before the due date rather than give vitamin k to the baby. If women want further information I will photocopy the current articles. I acknowledge I haven't been asked to do this for a while. The maternity unit issues a leaflet about vit k before giving it with mother's consent. Some women refuse and that is documented and left at that.

Kerri-Anne - NHS Community Midwife.


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Personally, I chose not to have Vitamin K injected into my baby at birth, as I did not want him welcomed to the world with an intramuscular injection. Given that the incidence of Haemorrhagic Disease of the Newborn is so very low (approx 1 in 5,000 gets it and 1 in 10,000 dies from it), I decided that if there were some indication that he might be at greater than average risk, eg preemie, or a traumatic birth by forceps, then he would have the injection.

However, the oral preparation seemed hardly worth bothering with, on the grounds that I understand the greatest risk is within the first three days, and it is reportedly hard to get enough oral Vitamin K into the baby in that period to make much difference.

The possible connection between injected Vitamin K and childhood cancers seems like a red herring to me - the purported link was found only in the UK and no correlation occurred elsewhere, which strongly suggests confounding factors. I attended a talk by Michel Odent at which he mentioned that this may by related to parental choice in other matters. In the UK we are free to refuse Vitamin K injections for our babies, as well as any immunisations. Certainly many parents do not realise that they have a choice, but a significant proportion do.

In contrast, Odent said that in some of the other countries studied, parents were not consulted about Vit K injections, and that some or all childhood immunisations were also compulsory or given without parental consultation. He suspected that the sort of parent in the UK who refused routine Vit K injections for their newborn, would also be doing other things differently from the control group. They might well be taking immunisations on a case-by-case basis, refusing some or all. They might well be health-conscious and well-informed, and might be rearing their children on good diets. There might be many other factors... but his suspicion was that refusal of the Vit K injection was a 'marker' for these other factors, and was not a direct cause of the increased cancer rate.

I would like to see more details of the stats and studies behind this theory - which countries were involved, and what are their procedures re Vit K injection for example - but it's certainly food for thought.


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> The possible connection between injected Vitamin K and childhood cancers > seems like a red herring to me - the purported link was found only in the UK > and no correlation occurred elsewhere, which strongly suggests confounding > factors.

This is oft-quoted but no other country uses the same preparation of Vitamin K as we do so like was not compared with like. While the link does not seem likely, the preparation used at the time contained, admittedly in very small quantities, a known carcinogen.

Sara


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The enzyme required to synthesise Vit K is not evident in the gut of the baby until it is three or more months old. Why? Nature doesn't normally get it this wrong.

I did come across a study which suggested that pollutants in the environment may be contributing to less effective clotting systems, but I don't believe that this was a contributing factor in the decision to introduce Vit K on a blanket scale by paediatricians. Anyway if there is any weight in the hypothesis, why aren't we being told more about it?

Lorna


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Do babies need more Vit K than they get naturally?

This is another part of the debate and I accept that there may be very good physiological reasons for why a newborn should not be overdosed on artificial Vitamin K.

Women with reasonable nutrition should probably have the "optimun" amount of vit k. Frye again "Healthy human milk from an unsupplemented mother contains a small amount of vit k". and I would suggest likely the right amount- but we need the evidence to counteract the utilitarian approach of supplementing babies.

The women we work with are encouraged about skin-to skin and to nurse frequently, but many choose to do otherwise and put their baby elsewhere in a moses basket! And there are issues about poor nutrition and chemical misuse as well.


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The Bristol study - Vitamin K injection linked to childhood leukaemia?
I believe that the original Bristol study started by looking at all babies born in Great Britain in one week of April 1970 (total=16,193). 33 developed cancer by 10 years of age. Three children without cancer were chosen as controls for each case.

Compared to the controls: mothers of children with cancer were slightly more likely to: bottlefeed; smoked 5+ cigs daily in pregnancy; used the Pill in the 18 months prior to conception, and had blood group other than A. There were statistically significant relationships between childhood cancers and: antenatal X-rays (including non-abdomen); antenatal smoking; gestation outside 39-41 weeks; `pethidine in labour'; drugs (predominately `vit K') to neonate. The greater the number of risk factors, the more likely to develop cancer. Only maternal smoking and neonatal drugs remained independently statistically significant (i.e. the pethidine link may be chance).

There were only a small number of cases, but there was some support for findings of others; i.e. childhood cancer was associated with antenatal X-rays, antenatal smoking and pethidine in labour. The vit K link was unexpected and needed more investigation... which they did!

The above is from notes that I made from an article in MIDIRS 1991(1:1), I keep it folded up in the back of my work diary along with some other information about vit K.

In MIDIRS June 1992 (2:2) there is a report on the 2nd Bristol study which looked at babies born in Bristol in 1965 and 1987. The criticisms were that all the data was from one hospital (so there could be other variables relating to the place), and poor records (either missing or method of administration not recorded). They said that the link with vit K (IM) may not be causal but suggest a 1:500 risk, double the normal risk. This article also mentions the risk of a `normal' baby developing HDN as 1:10,000. This is where it all started from... I could write more but I was on call last night and I need my beauty sleep!!

Some women who plan to nurse their babies take vitamin K supplements a few weeks before the due date rather than give vitamin K to the baby. Could you please tell us what evidence there is to support antenatal supplementation, as I thought it would not be absorbed by the fetus.

I wasn't suggesting that the woman takes it to supplement the foetus but rather to ensure that her own levels of vit K are optimum in her colostrum for when she commenced nursing the baby - sorry if that wasn't communicated. It is acknowledged that placental transportation is poor for this element of the clotting mechanism.

Is there any good evidence that the colostrum `contents' can be manipulated in this way? If it's thought babies need more vit K than they get, then just don't separate mothers and babies, also encourage skin-to-skin contact so there are lots of opportunities for small, frequent feeds, and feed unrestrictedly.

I agree completely with you. Women with reasonable nutrition should probably have the 'optimum' amount of vit K.

I do believe that there is some odd lack of evidence based-practice and some poor research around vit K.

Anne Frye's book is my main current source of what I consider to be credible information on the subject (Frye, UDT 1997 p857) her discussion goes on for pages and the quote below is taken out of this if, anybody wants anymore information she has a website and take the debate up with her:

Studies have shown that Vit K deficiency occurs primarily in babies receiving small amounts of breast milk or even small amounts of formula during the first days of life. Nursing should begin at birth and continue every two hours [I personally have a problem with this amount of prescriptive advice] or more often on demand. Be sure mothers understand that although the volume of colostrum is not great, it is the perfect food for their babies during the first few days and is important to prevent classical VKBD (Vitamin K Bleeding Disorder). If the mother supplements her diet with vit K, levels in breast milk begin to rise and are dramatically increased by 12 hours (Haroon, 1982). This was the first study to demonstrate such a response and further studies have conformed this finding (Sutor & Hathaway, 1994)

I don't know if this is good evidence not having checked out the original papers but it is a contribution to the picture.

I'd much rather the maternal metabolism deliver the necessary amount of vit K in breast milk than the NHS utilitarian approach of vit K supplements for all babies. However, there still may be individual babies who will need a supplement, there are documented case histories of HDN.


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I recently researched HDN following an enquiry by a mother, and discovered that to my surprise the rate of haemorrhagiic disease of the newborn is about 1 : 1000 , although the rate of the disease which is severe enough to lead to fetal demise is the 1: 10,000 we were all taught in our midwifery training.

Linda


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Oral Vitamin K
There has recently been a story in my local paper about a so called scandal at our local hospital regarding vitamin K to babies and risk of cancer. It seems that 'most' hospitals are giving an unlicensed product to parents and also that they are not informing parents of any possible dangers.

I am not a health professional but I understand that it is not uncommon to give unlicensed products like this. How should mums feel about this? What is the point of having a license if you can give the stuff to patients without one? .. Mums want to have confidence in their decisions - if we know there are risks we can weigh them up against the risks of not taking something/benefits of taking it and make an informed decision. But when a product is said to be unlicensed, it immediately makes the risks of consenting to it seem much much greater..

Kathy


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Orakay, one oral version of vit K, isn't licensed in the UK. We have been using it but parents are aware of this and sign a consent form. The reason for it not being licensed is that it's not worth it for drug companies. It's very unusual for paediatric drugs to have been trialled on children; the majority of drugs used on children have been tested on adults and the assumption is then made that they could be used on children. However that decision is made by the consultant caring for that child and they then take on liability, which is what our paeds did at our unit.

The initial reason for offering oral vit K was a study in Bristol that appeared to link injectable vit K with childhood leukaemia. This study has since been 'disproved' in that the findings haven't been reproducable! However as I don't know who paid for the research to be done I can't say if it's particularly correct.

Cate


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We always use Konakion MM Paediatric, which is licensed for use in the UK and may be given either I/M or orally. The woman's GP does the prescription, and the woman then collects and holds it until needed. Actually, at least half of our women choose not to give the baby vit K anyway.

Melanie


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Do you know if the IM preparation is stabalized in the same substance and is equally absorbed if ingested, as a made for oral admin preparation?

It was my undestanding that IM Vit K should not be given orally since the drug is not made for oral use. I think the manufacturer is concerned that IM preparations will not work orally.

The Vit K we use says IM and oral use. We give 1st dose in 4 hrs, 2nd dose at 7 days, 3rd dose monthly. If mums are breastfeeding and chose oral administration then the babe gets a dose monthly until she stops breastfeeding.

Anyway this whole Vit K issue is a bit of a worry. So many units do different things, so how can a woman know what is right? Logically I would think if we knew Vit K was beneficial we would all give it the same way.

I think the way the unit I work in prescribes Vit K for breastfeeding mothers conflicts with the advice that we give about breast is best but we will just add this Vit K to your baby since we think breastmilk doesn't have enough!!!


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Absolutely. The studies showing 'inadequate' Vit K (or rather, babies apparently at risk of HD being more likely to be breastfed) were carried out at a time when babies were more often separated from their mothers and feeds were timed and scheduled.

Heather


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My last breastfed baby received the IM prep. as oral, and had really bad colic for the rest of the night. The only time, I hasten to add. One of my colleagues had given it as an error, and when I checked it out with the pharmacist, they confirmed that the base that held the VitK was the probable cause of her discomfort. She is a thriving 2 year old, with no long term effects.

Oral VitK is not available where I live (WA, USA) so if women want oral (or some, none) that is their informed choice for a healthy birth and baby. What we do is give 3 doses of the Im, oral via a syringe 1st within 24hrs and within 5 days, 3rd within 6 weeks.

Denise


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After much lobbying by women, midwives and other Health professionals here in New Zealand, the prepared neonatal oral dose 2mg/0.2ml times three doses at the intervals of birth, 5 days and six weeks has been gazetted for introduction by Roche at the end of October by our Ministry of Health. It appears from reading the literature that as long as the three oral divided doses are given that it is as effective as the IM route. This decision has been a long time coming and very welcomed. I have very seldom in the past 10yrs given the IM dose orally as most woman and their families seldom use it as their first choice as the route of administration. I feel the phenyol and caster oil that is in the IM preparation to keep it stable is deterimental to the initiation of breast-feeding. Have a taste of the IM stuff yourself. Believe me the taste remains with you for sometime.


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Hate to say this, but so does the taste of the oral dose by Roche. We give only give a small amount of the recommended dose - 0.1ml at one unit, or 0.05ml t'other unit's prescription - but it still tastes disgusting!

Terri


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Konakion (Vitamin K) and Vegetarians
Readers might be interested to know that of the two Konakion preparations produced by Roche Pharmaceuticals, one is suitable for vegetarian babies and one is not. The details are as follows:

Konakion l mg/0.5 ml ampoule, for intra-muscular administration, is an animal free product. However, Konakion MM Paediatric (phytomenadione) 2 mg/0.2 m1 ampoule, for oral administration, has the gall bladders of cattle used as part of its production, and therefore might not be acceptable for parents of vegetarian babies.

In response to a request for information from Roche on this subject, they state that glycocholic acid, which is a component of the orally administered Konakion, is synthesised using cholic acid which is extracted from the gall bladders of cattle. In the preparation for IM administration however, glycocholic acid is not used and `therefore can be used as a suitable animal-free product if required'.

Midwives might find this information helpful if offering vitamin K to parents for their babies.

Belinda


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Thought you might be interested in the suggestion of a good reason for low vitamin K levels:

Observations on vitamin K deficiency in the fetus and newborn: has nature made a mistake?
AUTHORS: Israels LG; Israels ED
AUTHOR AFFILIATION: Department of Medicine, University of Manitoba,
Manitoba Institute of Cell Biology, Winnipeg, Canada.
SOURCE: Semin Thromb Hemost 1995;21(4):357-63
CITATION IDS: PMID: 8747698 UI: 96357538

ABSTRACT: The microsomal mixed function oxidase system metabolizes xenobiotics (Phase I) to products that, if not activated and conjugated for excretion (Phase II), are capable of forming conjugates with cellular macromolecules, including DNA, resulting in toxic, mutagenic, or carcinogenic events. Benzo(a)pyrene (BP), a polycyclic aromatic hydrocarbon, is a model carcinogen for this system. Vitamin K1 (phylloquinone) is a regulator of BP metabolism. These studies demonstrate that K1 is capable of increasing Phase I metabolism and decreasing glutathione transferase activity (Phase II) in chick embryo liver; that deprivation of K1 reduces BP/DNA adducts in mouse liver and reduces tumor formation in mice given intraperitoneal BP; and that K1 supplementation increases BP induced tumor formation in mice. However, epidemiologic studies indicate that children of mothers who smoke during pregnancy may not be at increased risk of cancer. It is known that the placentas from these pregnancies exhibit markedly increased levels of arylhydrocarbon hydroxylase induced by the polycyclic aromatic hydrocarbons in tobacco smoke, but there is no corresponding increase in this enzyme activity in the fetus in such pregnancies. We suggest that the low vitamin K level is a secondary protective mechanism for xenobiotics, such as BP, that may escape the primary placental screen. The recently described role of vitamin K-dependent Gla protein as ligands for receptor tyrosine kinases, also establishes K as a link in cell growth and transformation. It is proposed that the small total body pool of K1 in the adult, which is sufficient only to meet continuing needs, and the even smaller pool in the fetus are protective. This protective effect of low K1 levels is particularly important in the presence of the high mitotic rates and rapid cell turnover in the avian embryo and mammalian fetus.


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When Vitamin K administration may be unwise...Factor Van Leiden Blood Clotting Disorder
Midwifery Today E-News (Vol 2 Issue 19) is a special on Factor V Leiden (FVL) - a genetic condition which increases the chances of blood clots developing. Depending on the area, between 3% and 10% of caucasian people carry the FVL gene; no stats are given for people from other ethnic groups, and it is implied that it is a caucasian anomaly. The baby of someone carrying FVL has a 50% chance of carrying it too, and the author speculates that routine vitamin K administration could be dangerous for these babies. Interesting thought - and how many areas routinely test women for the condition? If they don't, routine vitamin K adminitration could be putting their babies at risk.

I've copied an excerpt below:

o=o=o=o=o=o=o MIDWIFERY TODAY E-NEWS :a publication of Midwifery Today, Inc. (www.midwiferytoday.com)
Volume 2 Issue 19 May 12, 2000
Factor V Leiden Code 940
o=o=o=o=o=o=o

All the following information on Factor V Leiden has been prepared by Jennifer Rosenberg, CD (DONA).

Pregnancy, Clotting, and Factor V Leiden: An Overview

The past 10 years have brought new understanding of and explanations why some women clot on birth control pills and during pregnancy. Research into genetic origins of disease has uncovered many coagulopathies, some of them surprisingly common. The most common is Factor V Leiden, also known as Activated Protein C Resistance, which carries a 3-10 times greater risk of clot when someone has one copy of the gene and 30-140 times greater risk of clotting for someone with two copies.

Between 3% and 10% of Caucasian people are heterozygous for Factor V Leiden, and a much smaller percentage are homozygous. In Sweden the rate of heterozygous mutation may be as high as 15% in some areas, while in other parts of the world and among other races only a fraction of a percent of the population may have it. It is thought that the original mutation occurred as much as 20,000-30,000 years ago in a single individual.

Women with Factor V Leiden (FVL) have a substantially increased risk of clotting in pregnancy (and on estrogen containing birth control pills or hormone replacement) in the form of DVT (deep vein thrombosis, sometimes known as "milk leg") and pulmonary embolism. They also have an increased risk of preeclampsia, as well as miscarriage and stillbirth due to clotting in the placenta, umbilical cord, or the fetus (fetal clotting may depend on whether the baby has inherited the gene). Note that many, many of these women go through one or more pregnancies with no difficulties, while others may miscarry over and over again, and still others may develop clots within weeks of becoming pregnant.

... Remember that approximately one in twenty of the women you serve will have FVL. Approximately one in a hundred of women with FVL (estimates vary radically from a 1% thrombosis rate (4) to a 25% thrombosis rate (my hemotologist) will have a serious DVT during pregnancy...

FVL is inherited. This means that for every pregnant woman who has FVL, the child she carries has at least a 50% chance of inheriting the disease (more if the father also has it). ..

Vitamin K encourages clotting, and thus there is some concern among parents with FVL about giving their newborns the prophylactic vitamin K bolus. At the very least such treatment should NOT occur immediately after birth, when hormone levels are still up, in my opinion as a parent. And it may be advisable (though research has not been done!) to do the quick screening test for FVL (not the genetic test; this test simply checks to see how resistant clots are to activated protein C) prior to giving the infant vitamin K later. Perhaps testing cord blood for APC resistance immediately after birth and only giving negative babies vitamin K would be reasonable. Another approach would be to delay the vitamin K shot for 6-12 hours if not longer, to allow hormone levels to drop. I am aware of one family that feels their baby's death was caused by the vitamin K shot. Although the story is completely anecdotal, it echoes fears I had with my own daughter.

(End of excerpt from Midwifery Today E-news. Please visit the Midwifery Today website at www.midwiferytoday.com.)


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Other sources of information:
For info on Vitamin K the MIDIRS midwifery digest is unparallelled. They also have a collection of references on it. Most recent info in MIDIRS is in the 1998 issues, and not much has happened since then in the way of research. There is far too much to do it justice in an on-line discussion here.

MIDIRS: www.midirs.org

Rachel


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AIMS Occasional Paper - Vitamin K in relation to haemorrhagic disease of the newborn, by Joan Donley, OBE It is available from the Publications Secretary, 2 Bacon Lane, Hayling Island, Hants, PO11 ODN, costs £2.50 incl. p&p.

AIMS: www.aims.org.uk

And one more:

The Vitamin K Controversy

The forces of nature are so focused on a successful birth that it just seems unlikely that all babies are deficient in vitamin K. Instead of simply accepting that nature goofed about clotting factors in newborns, I thought about all the ways that interventions at birth interfere with the normal physiological birth process regarding clotting. The most obvious intervention is premature cutting of the umbilical cord; this deprives a newborn of 25% to 40% of the physiological blood volume, and thus 25% to 40% of the physiological clotting factors that nature intended to be present in the newborn's blood. As someone who does Newborn Screening heelsticks on newborns whose umbilical cords were not cut prematurely (and some of whom did not receive supplemental vitamin K), I can tell you that they have no trouble clotting normally. This solves the problem of early-onset or classical HDN.

Although vitamin K doesn't pass easily from the mother's bloodstream to the newborn through the placenta, it DOES pass easily through breastmilk. (Doesn't this seem like a strong clue that nature is actually protecting the baby somehow by managing the clotting factors in a very specific way?) Women who eat lots of fresh, leafy green vegetables will pass the vitamin K through to their babies, and this will protect them from late-onset HDN.

So, maybe nature got it right, after all, and all we have to do is support physiological health by waiting at least 5 minutes after the birth to cut the cord and by encouraging nursing mothers to eat lots of fresh, leafy green vegetables (or take a vitamin K supplement).

Some exceptions are:

Some maternal medications interfere with vitamin K, such as anticonvulsants, anticoagulants, and antibiotics. [Maternal vitamin K supplementation that is administered prenatally may prevent this form of HDN.

Vitamin K generation is also inhibited in babies who have received antibiotics.

A very few babies will have a liver disorder that prevents the normal production of vitamin K in the newborn's gut; symptoms tend to appear slowly.

Other risk factors include diarrhea, hepatitis, cystic fibrosis (CF), celiac disease, and alpha1-antitrypin deficiency.

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Prophylactic vitamin K for vitamin K deficiency bleeding in neonates (Cochrane Review)

Main results
Two eligible randomized trials, each comparing a single dose of intramuscular vitamin K with placebo or nothing, assessed effect on clinical bleeding. One dose of vitamin K reduced clinical bleeding at 1-7 days, including bleeding after circumcision, and improved biochemical indices of coagulation status. Eleven additional eligible randomized trials compared either a single oral dose of vitamin K with placebo or nothing, a single oral with a single intramuscular dose of vitamin K, or three oral doses with a single intramuscular dose. None of these trials assessed clinical bleeding. Oral vitamin K improved biochemical indices of coagulation status at 1-7 days. There was no evidence of a difference between the oral and intramuscular route in effects on biochemical indices of coagulation status. A single oral compared with a single intramuscular dose resulted in lower plasma vitamin K levels at two weeks and one month, whereas a 3-dose oral schedule resulted in higher plasma vitamin K levels at two weeks and at two months than did a single intramuscular dose.

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Vitamin K at Birth: To Inject or Not By Linda Folden Palmer, DC, author of Baby Matters

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Vitamin K--what, why, and when. [Full text]
Hey E.
Arch Dis Child Fetal Neonatal Ed. 2003 Mar;88(2):F80-3.

"Policies for giving babies vitamin K prophylactically at birth have been dictated, over the last 60 years, more by what manufacturers decided on commercial grounds to put on the market, than by any informed understanding of what babies actually need, or how it can most easily be given. By a pure fluke a 1 mg IM dose, designed to prevent early vitamin deficiency bleeding ("haemorrhagic disease of the newborn") has been found to protect against late deficiency bleeding-a condition unrecognised at the time this policy took hold. Alternative strategies for oral prophylaxis are now opening up (see pp 109 and 113), but these are also, at the moment, dictated more by what the manufacturers choose to provide than by what would make for ease of delivery either in poor countries, or in the developed world."

From the full-text paper:

CONCLUSION - So what have we learnt in the last 64 years? That babies have very limited reserves of vitamin K at birth, and that some will soon bleed if a continuing intake is not guaranteed. We also know that a few "supplements" of cows milk50 or formula milk14 can suffice to restock those reserves, and that there is really no case for giving the healthy, artificially fed, baby further supplementation, either by injection or by mouth, other than administrative convenience. Babies who are not fed, and a very small number of fully breast fed babies, will develop symptomatic deficiency. Without prophylaxis the risk of early (easily recognised) bleeding in a healthy non-traumatised term baby in the first two weeks of life is probably only 1–2 in a thousand. The risk of a later (potentially more dangerous) bleed is perhaps a third of that. Both these risks can be virtually eliminated by giving a single 1 mg intramuscular "depot" injection of phytomenadione, or by giving the baby 1 mg by mouth once a week for the first three months of life. Indeed the only babies not protected by four 1 mg (or three 2 mg) oral doses, if well spaced out, are those with some as yet unrecognised liver disease.36,48
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Vitamin K - An Alternative Perspective
Midwife Sara Wickham provides a much-needed update on vitamin K prophylaxis.
AIMS Journal, Summer 2001, Vol 13 No 2
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From a WHO (World Health Organization) publication - "Care in the first hours includes: . . .

* administering vitamin K to the baby if country policy prescribes it, either by injection or orally. However, the evidence for routine administration of vitamin K to all newborns to prevent the relatively rare haemorrhagic disease of the newborn is still lacking.

It occurs to me that WHO has much more exposure to physiological birth practices than other evidence-based recommendations bodies, such as the Cochrane Collaboration. And given that WHO works on health issues for those who often have very poor nutrition, you'd think they would have noticed problems with HDN or vitamin K deficiency if it were seen in cases where the cord is left intact for a few minutes after the birth.

Sara Wickham's writing points out that HDN or vitamin K deficiency was not reported in the literature before the modern practice of premature cutting of the umbilical cord at birth.

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The purpose of vitamin K is to increase the clotting factors for a newborn. But is that always a good idea?

This web page on Summary

4G/5G promoter polymorphism in the plasminogen-activator-inhibitor-1 gene and outcome of meningococcal disease. Meningococcal Research Group.
Hermans PW, Hibberd ML, Booy R, Daramola O, Hazelzet JA, de Groot R, Levin M
Lancet 1999 Aug 14;354(9178):556-60

Variation in plasminogen-activator-inhibitor-1 gene and risk of meningococcal septic shock.
Westendorp RG, Hottenga JJ, Slagboom PE
Lancet 1999 Aug 14;354(9178):561-3
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Vitamin K for newborns - why & what risks? - from Danny Tucker's pages
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How do Parents Decide about Vitamin K?
If there were absolutely no risks or costs associated with vitamin K administration or the shot, nobody would argue against it.
However, an injection creates an avenue of infection for a newborn with an immature immune system in an environment that contains the most dangerous germs. In addition, the possible trauma from the injection can jeopardize the establishment of breastfeeding, which does much more to protect the baby's health than vitamin K injections have ever been alleged to do. At the very least, the injection should be delayed until after the baby has learned to nurse.

I've sometimes wondered whether there's a connection between vitamin K administration and SIDS. Some studies have shown a lower incidence of SIDS among breastfed babies, and we know that breastmilk is lower in vitamin K. Who knows? Nobody, really. Why are we messing with delicate systems we don't understand?

There is likely a very complex relationship between baby's blood volume (which is reduced by as much as 40% with immediate cutting of the umbilical cord), and the baby's vitamin K and iron levels. It may be that when a baby is allowed to receive all its blood from the placenta, the coagulation factors are more than adequate to prevent hemorrhage.

Given the study that claims that vitamin K levels are not associated with clotting factors, it might be that the best thing parents can do to prevent hemorrhage in newborns is to insist that their babies be allowed to get all their blood back from the placenta after birth. Those would seem to be the clotting factors of greatest use to the baby.

Maybe the association between traumatic birth and newborn hemorrhagic disease is really an association between traumatic birth and early cutting of the cord, which is more likely with a traumatic birth where the baby is rushed across the room for resuscitation. Maybe someday hospitals will develop the sophistication to be able to perform any needed resuscitation without cutting off the baby's oxygen and blood supply.

Until we have the definitive answers to these questions, parents have to choose between a system that's been in place for less than a hundred years and one that's been in place for thousands of years.

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General Discussion about Controversy over Administration of Vitamin K to Newborns

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It has been suggested that if the mother takes oral Vit K, during the last trimester, that there would not be a need for the newborn shot. Anyone know of a study related to this? I have seen a number of clients in this area that choose to take the prenatal Vit K in order to avoid the shot for their newborn.

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There really is little known about the physiologic process of vitamin k absorption and blood factor response. Supplementation was started before the norms were known -- and the dosage was set almost at random (with little research first).

there are a lot of questions being asked now -- especially since it's been found that the IM levels are much higher than needed, and might be harmful.

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Hemorrhagic Disease of the Newborn Really Low Blood Volume from Early Cord Cutting?
Maybe the association between traumatic birth and newborn hemorrhagic disease is really an association between traumatic birth and early cutting of the cord, which is more likely with a traumatic birth where the baby is rushed across the room for resuscitation.

Research

Vitamin K Abstracts

Study Supports Maternal Vitamin K Supplementation for Breastfeeding Mothers as Alternative to Newborn Administration
Vitamin K prophylaxis to prevent neonatal vitamin K deficient intracranial haemorrhage in Shizuoka prefecture.
Nishiguchi T, Saga K, Sumimoto K, Okada K, Terao T
Br J Obstet Gynaecol 1996 Nov;103(11):1078-1084
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Coagulation Factors Not Related to Vitamin K Levels
Vitamin K1 levels and coagulation factors in healthy term newborns till 4 weeks after birth.
Pietersma-de Bruyn AL, van Haard PM, Beunis MH, Hamulyak K, Kuijpers JC
Haemostasis 1990;20(1):8-14

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Plasma concentrations after oral or intramuscular vitamin K1 in neonates.
McNinch AW, Upton C, Samuels M, Shearer MJ, McCarthy P, Tripp JH, L'E Orme R.
Arch Dis Child. 1985 Sep;60(9):814-8.

"One hundred and seven healthy, breast fed infants received 1 mg vitamin K1 either at birth (orally or intramuscularly) or with the first feed (orally). Venous blood samples collected in the next 24 hours were assayed for plasma vitamin K1. In babies given the vitamin orally at birth, the peak median concentration (73 ng/ml) occurred at four hours. By 24 hours median plasma concentrations had fallen to 23 ng/ml and 35 ng/ml in the groups fed vitamin K1 at birth or with the first feed, respectively; this difference was not, however, significant. Plasma concentrations after intramuscular injection exceeded those in the oral groups at all comparable times, with a peak median concentration of 1781 ng/ml at 12 hours falling to 444 ng/ml at 24 hours. Since median plasma vitamin K1 concentrations 24 hours after oral administration were some 100 times and 1000 times greater than previously estimated adult and newborn values respectively, this study supports giving vitamin K1 orally at birth to well, mature babies to protect against early haemorrhagic disease of the newborn. Further studies are needed to determine the optimum dose for protection over subsequent weeks."

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[Effect of oral and intramuscular vitamin K on the factors II, VII, IX, X, and PIVKA II in the infant newborn under 60 days of age] [Article in Spanish]
Arteaga-Vizcaino M, Espinoza Holguin M, Torres Guerra E, Diez-Ewald M, Quintero J, Vizcaino G, Estevez J, Fernandez N.
Rev Med Chil. 2001 Oct;129(10):1121-9.

BACKGROUND: Neonates on exclusive breast feeding that do not receive vitamin K at birth are at higher risk hemorrhagic disease of the newborn. AIM: To compare the effect of oral or intramuscular administration of vitamin K1 (VK1), on clotting factors II, VII, IX, X and PIVKA II, in children until the 60 days of age with exclusive breast feeding or mixed feeding. PATIENTS AND METHODS: Forty healthy full term infants, distributed in two groups, A: 20 with mixed feeding (formula-feeding and breast-feeding) and B: 20 with exclusive breast feeding, were studied. Nine infants of each group received 1 mg of VK1 intramuscularly and eleven 2 mg VK orally 5 ml of cord blood was collected initially from each infant. Venous blood samples were taken on 15, 30 and 60 days of age. RESULTS: All factors increased in a progressive form reaching levels over 50% at 60 days of age, in both groups. PIVKA II decreased significantly during the study period (p < 0.01). Factor II increased more in children with mixed feeding that received intramuscular vitamin K, than in the rest of study groups. No other differences between groups were observed. No infant had an abnormal bleeding during the study period. CONCLUSIONS: Oral administration of vitamin K is as effective as the intramuscular route in the prevention of the hemorrhagic disease of the newborn.
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[Vitamin K 1 concentration and vitamin K-dependent clotting factors in newborn infants after intramuscular and oral administration of vitamin K 1] [Article in Hungarian]
Goldschmidt B, Kisrakoi C, Teglas E, Verbenyi M, Kovacs I.
Orv Hetil. 1990 Jun 17;131(24):1297-300.

Serum concentration of vitamin K1 and activity of vitamin-K-dependent factors II, VII, IX and X were determined before and after vitamin K1 administration in infants. The babies received vitamin K1 intramuscularly or orally. 12 hours after vitamin K1 treatment the mean concentration was increased in the groups receiving vitamin K1 intramusculary or orally, respectively. Serum level of vitamin K1 fell exponentially, the mean half life was about 30 hours in both groups. Activity of vitamin K-dependent clotting factors did not change significantly after intramuscular or oral vitamin K1 administration during the first four-five days of life. It was no direct correlation between the concentration of vitamin K1 and the activity of vitamin-K-dependent clotting factors. This study suggest that oral administration of vitamin K1 is as effective as the intramuscular route. [Remember that prevention effectiveness continues even after the supplemented K levels drop.]

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Vitamin K Protocols
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From Nursing Times, October 14, 1998:

Researchers have found that plasma vitamin K concentrations were at least equal to or significantly higher in babies who are given the new oral form compared to those who are given the vitamin via injection. The oral form is given in doses of 2 mg soon after birth and again four to seven days later. It has been recommended that if the baby is being breastfed, an additional dose be given when it is one month old.
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I have mom take oral Vit. K for two weeks prior to EDD. I find this helps bleeding pp as well. Then I give baby 2 drops at birth (before I leave) and then again on day five.

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I'm curious why you give 2 drops of vitamin K. I was thinking that I would need to give them the same amount of mgs as I would of the synthetic. Do you know more about this, any study on this, or suggested amount. When I worked at a birth center they gave the injectable orally, and it was 50mg. Just wondering what you think about giving the natural vit. K in the same dose.

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I give the same dose PO as is suggested for IM. Some, I have heard, do double the dose when giving it PO.

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we give three doses, following one of the european protocols (birth, one week, three weeks). Not certain whether this is needed or not, but what the heck... perhaps is does extend protection and lessen the low incidence of late onset hemorrhagic disease. The dose is two drops.

How does it taste? I've tasted it! One brand (aquamephytin) tasted rather fishy -- not gawdawful, just not my favorite flavor! babies seem to get down the two drops without flinching.

the brand we've been using for a while is alphalpha-derived (I hear) and doesn't have much taste at all.

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How to Administer Vitamin K Orally
I've seen Vitamin K administered orally as follows: The Vitamin K is drawn up as if for the injection, although you draw up a double dose for oral administration. Once the fluid is in the syringe, you remove the needle. Then you help the baby to be as comfortable as possible, insert the syringe into the side of the baby's mouth so the tip is kind of in the back corner behind the taste buds. Then you slowly push the plunger to push the fluids into the baby's mouth. If done slowly and gently, this doesn't seem to bother them.

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Although this article is about very low-birth weight babies, it's interesting because of the relationship between delayed cord clamping and protection from IVH (Intraventricular Hemorrhage) and LOS (Late-Onset Sepsis). This is the closest information we have about the protective effect of delayed cord clamping against HDN for term babies.

Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized, controlled trial.
Mercer JS, Vohr BR, McGrath MM, Padbury JF, Wallach M, Oh W.
Pediatrics. 2006 Apr;117(4):1235-42.

RESULTS: Seventy-two mother/infant pairs were randomized. Infants in the ICC and DCC groups weighed 1151 and 1175 g, and mean gestational ages were 28.2 and 28.3 weeks, respectively. Analyses revealed no difference in maternal and infant demographic, clinical, and safety variables. There were no differences in the incidence of our primary outcomes (BPD and suspected NEC). However, significant differences were found between the ICC and DCC groups in the rates of IVH and LOS. Two of the 23 male infants in the DCC group had IVH versus 8 of the 19 in the ICC group. No cases of sepsis occurred in the 23 boys in the DCC group, whereas 6 of the 19 boys in the ICC group had confirmed sepsis. There was a trend toward higher initial hematocrit in the infants in the DCC group. CONCLUSIONS: Delayed cord clamping seems to protect VLBW infants from IVH and LOS, especially for male infants.

Here's the Reuter's version:

Thursday, April 6, 2006

By Clementine Wallace

NEW YORK (Reuters Health) - Waiting 30 to 45 seconds before clamping the umbilical cord of very low birth weight infants -- those weighing less than 1500 grams -- seems to protect them against bleeding in the brain and the development of blood infections later on, researchers report.

The strategy seems to benefit boys especially.

"While countries in Europe tend to wait before clamping these children's umbilical cord, the current practice in the United States is to clamp it immediately after delivery," Judith Mercer told Reuters Health. "There hasn't been a lot of research done in this country on delayed cord clamping, and most studies were limited by small samples."

Evidence is accumulating to suggest that, for very low birth weight infants, delaying cord clamping and lowering the newborn below the mother's level significantly increase the amount of blood flowing from the placenta to the newborn, according to Mercer, from the University of Rhode Island in Kingston.

In their article in the medical journal Pediatrics, she and her colleagues note that waiting 30 to 45 seconds results in an 8 percent to 24 percent increase in the baby's blood volume.

"Immediate cord clamping may deprive these infants of essential blood volume, which might result in hypotension (low blood pressure) and in a poor perfusion of the tissues," Mercer explained.

Her group's study involved 72 pregnant women who gave birth to infants before the 32nd week of gestation. The women underwent either immediate cord clamping at 5 to 10 seconds after the birth, or delayed cord clamping 30 to 45 seconds after delivery.

The researchers saw differences between the two groups in rates of brain bleeds in the babies, and in their risk of late-onset sepsis.

These differences were significant from a statistical standpoint in male infants, but not in females. Specifically, 2 of the 23 male infants in the delayed-clamping group had intraventricular hemorrhage compared to 8 of the 19 in the immediate-clamping group. No case of sepsis occurred among the first group, whereas 6 cases occurred among the others.

The researchers say the strategy is a simple way to improve outcomes of very preterm infants.

SOURCE: Pediatrics, April 2006.

I guess it is interfering with nature. No-one knows why babies are born with lower levels of vit K.. but if you think about it, we're nourishing the baby completely inside the womb.. and we nourish them completely outside the womb too.. only difference is they breathe for themselves! So nature must know what it's doing

btw.. woah at the long posts Kelly! LOL

I read that baby doesn't produce vitamin K because it is produced from the bactiria in the gut & they don't have that straight off. Also that its not passed from mother to baby while in the womb & vrey little from BFing.
I will read Kellys post later.

Hi, Where did you get the oral vitamin k, and who gives it to the infant please?

Usually in the hospital (if you have a hossy birth that is) and normally given by midwives.

Ive only ever had the injection one as its 1 does not 2 or 3 like oral

DD had one dose right after birth then one at 3 days at the hospital. Her third dose will be done at our 6 week appointment with our GP.

Sarah, just out of curiosity, did anyone give you a hard time about giving J the oral doses, rather than the jab?

The first one I don't know cos she was in SCN at the time & I was in recovery after the c/s. The second one was fine, she didn't seem bothered by it at all.

We were going to do the vit k orally and the midwives didn't care- brought us the forms to sign with oral indicated etc. But when it came to it they suggested that the injection may be better as our son had a large bump/bruise on his head and we agreed. They weren't at all pushy though and the injection wasn't given until he was about 6/7 hours old when they did the other routine stuff (like weighing) as well.

I asked about having it given orally, but since we were leaving the hospital same day it was strongly suggested we have it given by injection, and we agreed. It probably wasn't totally necessary as there was no bruising or blood loss, but I don't regret doing it.

I had my middie appointment yesterday and she mentioned a natural vitamin thing you can take to increase Vitamin K production in your breastmilk but I've forgotten. Does anyone know what it is? I'll have to ask her at our next appointment otherwise. No big drama just wanted to research about it.

Helen

i had started another thread on this cuz i didn't know this one existed.. whoopsie.
I'm kinda stuck between a rock and a hard place on this one....
I personally think that the fact that we are able to support a baby for 9 months by eating the right foods and then breast milk after is meant to supply a baby adequaetly with everything it needs - then why do they need an extra vitamin dose....(i understand premmie or traumatic births are different - but if full term no complications )??
If vitamin k is to do with something in the gut - well of couse it's levels will be lower than that of a child who is even 6 weeks (which i read is when it's at a normal level) because they don't use their gut/stomach to digest food before they are born? So i don't understand why we should mess this system up; yes it is sad the fact that some babies can die... but you've got that risk with anything thing.

on the other hand, medicine has come along way in improving our lives and preventing some illnesses so if this seems to work then why not?

grrr tough one really.... i'm the same on the immunisation front. in a way these injections haven't really been around long enough for alot of studies to be done on their negative effects... but in the short term they seem to work