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The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

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Administration of Vitamin K to Newborns

Why women shouldn't fear home birth
by Mayim Bialik, Ph.D.
This short essay is humorous, honest, insightful and inspiring.

Subsections on this page:



Updated Observations



It is unfortunate that the current standard of care regarding Hemorrhagic Disease of the Newborn and vitamin K is still experimental; early results were put into practice without adequate research to determine best practices.

Therefore, practitioners are in a difficult place regarding what to recommend.

If you just want to protect yourself legally with the least amount of trouble, then you'll probably want to recommend the standard vitamin K injection at birth.

If you want to provide the best care, you'll work to ensure that baby has a trauma-free birth and gets all the blood nature intended through Optimal Cord Clamping.  Then you'll encourage parents to agree to either injected or oral vitamin K shortly after the birth and then empower them to continue giving at least weekly doses of oral vitamin K for three months.

Even babies who have received injectable vitamin K at birth have developed VKDB.  All babies need ongoing oral vitamin K at least weekly for three months.



Revisiting vitamin K and the newborn: what have we learned in a decade? by Sara Wickham (2013)

1 in 14,000 to 1 in 25,000 babies who do not receive vitamin K are affected by late VKDB.  . . .  Ten years ago, Hey (2003b) observed that policies around vitamin K administration had been dictated more by what manufacturers decided to market than by any kind of informed understanding of what babies need.  . . . A Danish study revealed no cases of VKDB in about 396,000 babies who received weekly oral prophylaxis of 1 mg per week from birth until they reached three months of age (Hansen et al 2003).

This article has a GREAT bibliography!!!



Weekly oral vitamin K prophylaxis in Denmark.
Hansen KN1, Minousis M, Ebbesen F.
Acta Paediatr. 2003 Jul;92(7):802-5.

RESULTS: No cases of VKDB were revealed, i.e. the incidence was 0-0.9:100000 (95% CI).
CONCLUSION: Weekly oral vitamin K supplementation during the first 3 mo of life was an efficient prophylaxis against VKBD. Parental compliance with the regimen was good.

[Ed: Parental compliance is bolstered by having them program a weekly reminder into their computer calendar.]



Prevention of vitamin K deficiency bleeding with three oral mixed micellar phylloquinone doses: results of a 6-year (2005-2011) surveillance in Switzerland.

Laubscher B, Bänziger O, Schubiger G; Swiss Paediatric Surveillance Unit (SPSU).
Eur J Pediatr. 2013 Mar;172(3):357-60. doi: 10.1007/s00431-012-1895-1. Epub 2012 Nov 29.

In 2003, the Swiss guidelines to prevent vitamin K deficiency bleeding (VKDB) were adapted. As two oral doses (2 mg, hour/day 4) of mixed micellar VK preparation had failed to abolish late VKDB, a third dose (week 4) was introduced. This report summarizes the new guidelines acceptance by Swiss pediatricians and the results of a prospective 6-year surveillance to study their influence on the incidence of VKDB. The new guidelines acceptance by Swiss pediatricians was evaluated by a questionnaire sent to all pediatricians of the Swiss Society of Paediatrics. With the help of the Swiss Paediatric Surveillance Unit, the incidence of VKDB was monitored prospectively from July 1, 2005 until June 30, 2011. Over a 6-year period (458,184 live births), there was one case of early and four cases of late VKDB. Overall incidence was 1.09/10(5) (95 % confidence intervals (CI) 0.4-2.6). Late VKDB incidence was 0.87/10(5) (95 % CI 0.24-2.24). All four infants with late VKDB had an undiagnosed cholestasis at the time of bleeding; parents of 3/4 had refused VK prophylaxis, and in 1/4, the third VK dose had been forgotten. Compared with historical control who had received only two oral doses of mixed micellar VK (18 cases for 475,372 live births), the incidence of late VKDB was significantly lower with three oral doses (Chi(2),Yates correction, P = 0.007).

VKDB prophylaxis with 3 × 2 mg oral doses of mixed micellar VK seems to prevent adequately infants from VKDB. The main risk factors for VKDB in breast-fed infants are parental VK prophylaxis refusal or an unknown cholestasis.



Vitamin K; did nature get it right?
Cranford M.
Midwifery Today Int Midwife. 2011 Summer;(98):28, 66. No abstract available.

This article has some interesting observations about the issues of thermoregulation and thrombosis.

The authors postulate that "increases in platelets, red cells and viscosity associated with normal thermoregulatory adjustments to mild surface cooling provides a probable explanation for rapid increases in coronary and cerebral thrombosis in cold weather" (keating et al, 1984).  If adults experience thrombosis due to increased platelets and blood viscosity, which results from slightly lower body temperatures, wouldn't a physiologically born neonate also be at risk for thrombosis if he had a full quota of clotting factors, since he already possesses increased blood viscosity and platelets and is learning to thermoregulate?



Vitamin K, an update for the paediatrician.
Van Winckel M, De Bruyne R, Van De Velde S, Van Biervliet S.
Eur J Pediatr. 2009 Feb;168(2):127-34. doi: 10.1007/s00431-008-0856-1. Epub 2008 Nov 4.

DATA: Newborn babies are at particular risk of vitamin K deficiency, as placental transfer is limited and human milk is a poor source. Vitamin K prophylaxis at birth effectively prevents vitamin K deficiency bleeding (VKDB), formerly known as "haemorrhagic disease of the newborn". Recent epidemiological studies provide data on the effectiveness of different administration routes and dosing schemes. Infants of mothers taking drugs that inhibit vitamin K are at risk of early VKDB and should receive 1 mg intramuscular (i.m.) as soon as possible after birth. Classic VKDB is prevented by intramuscular as well as by oral administration of 1 mg vitamin K. In exclusively breast-fed infants, single i.m. administration at birth is also effectively preventing (rare) late VKDB but single oral administration is not. If given orally, prophylaxis should be continued by either weekly administration of 1 mg till 12 weeks or repeating 2 mg at weeks 1 and 4. Daily administration of 25 microg offers insufficient protection. The only infants not fully protected in this way are those with yet unrecognised liver disease.

K-QUINONE  from Scientific Botanicals Inc. contains 2 mg per drop of Vitamin K-1 (as Phytonadione).



Vitamin K in neonates: facts and myths. [full text]
Lippi G, Franchini M.
Blood Transfus. 2011 Jan;9(1):4-9. doi: 10.2450/2010.0034-10. Epub 2010 Sep 13.

Although both intramuscular and oral administration of 1 mg of vitamin K protect against classical VKDB, a single oral dose does not protect all infants against late VKDB. The intramuscular route of administration of vitamin K prophylaxis has, therefore, been universally adopted, but oral administration should be continued subsequently, according to one of the available guidelines (Table I). This approach seems to effective at preventing VKDB, but also has some drawbacks, the foremost being the fact that available commercial products cost a hundred times more than the basic cost of their one active ingredient, so that broadening this policy to developing countries might be challenging22.

This has an excellent Summary of the available recommendations about vitamin K administration in neonates.



[New Dutch practice guideline for administration of vitamin K to full-term newborns].
[Article in Dutch]
de Winter JP, Joosten KF, Ijland MM, Verkade HJ, Offringa M, Dorrius MD, van Hasselt PM; Spaarne Ziekenhuis, afd. Kindergeneeskunde.
Ned Tijdschr Geneeskd. 2011;155(18):A936.

Vitamin K-deficiency can cause haemorrhage in newborns and infants from the first hours up to several months after birth. These 'vitamin K deficiency bleedings' (VKDB) can be divided into 3 forms: early (occur in the first hours after birth), classic (first week after birth) and late (between the 2nd and the 12th week of life). The current Dutch vitamin K practice guideline consists of prophylactic administration of 1 mg vitamin K orally directly after birth and a daily dose of 25 μg from day 8 onwards. The current prophylactic treatment provides good protection against VKDB for healthy, breastfed infants. However, the current prophylactic treatment provides insufficient protection for a specific group of infants, namely breastfed infants with defective fat absorption (in cholestasis), leading to less efficient absorption of vitamin K by the body. Anually approximately 5 infants from this group suffer serious haemorrhage. After evaluation of current literature and advice from The Health Council of the Netherlands, vitamin K dosage was adapted for all breastfed infants from day 8 to 3 months (12th week of life) following birth: the daily dose was raised from 25 µg to 150 µg per day.


[Vitamin K supplementation in the exclusively breast-fed infant: how much, how long?].

[Article in French]
Zix-Kieffer I.
Arch Pediatr. 2008 Sep;15(9):1503-6. doi: 10.1016/j.arcped.2008.06.018. Epub 2008 Aug 6.

There are various ways to prevent late vitamin K deficiency bleeding in exclusively breast-fed infants. The French paediatric society recommends weekly doses of 2mg of mixed micellar preparation of vitamin K during the entire period of exclusive breastfeeding, i.e. 24 doses for a period of six months, which matches recommendations for optimal duration of exclusive breastfeeding by the French paediatric society, WHO and AAP. This significantly exceeds recommendations in other European countries. We describe the risks of vitamin K deficiency; we provide a review of recent literature about administrating vitamin K in other countries, and give a recommendation for daily practice that seems to be acceptable. Nevertheless, a comprehensive randomised prospective study is needed in France to answer the question of the best ways of preventing vitamin K deficiency bleeding.


Prevention of vitamin K deficiency bleeding in breastfed infants: lessons from the Dutch and Danish biliary atresia registries.
van Hasselt PM, de Koning TJ, Kvist N, de Vries E, Lundin CR, Berger R, Kimpen JL, Houwen RH, Jorgensen MH, Verkade HJ; Netherlands Study Group for Biliary Atresia
Pediatrics. 2008 Apr;121(4):e857-63. doi: 10.1542/peds.2007-1788.

A daily dose of 25 microg of vitamin K fails to prevent bleedings in apparently healthy infants with unrecognized cholestasis because of biliary atresia. One milligram of weekly oral prophylaxis offers significantly higher protection to these infants and is of similar efficacy as 2 mg of intramuscular prophylaxis at birth. Our data underline the fact that event analysis in specific populations at risk can help to evaluate and improve nationwide prophylactic regimens.


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 article:

It has also become clear that oral prophylaxis can be as reliable as intramuscular prophylaxis (for further evidence relating to this statement see the web site: www.bmjpg.co.uk/books/neonatalformulary/chapters/ vitk2comment.htm). What matters here is not so much the total dose given as the need for the dose regime to allow for the fact that natural body stores are low and turnover is rapid (a realisation that reinforces the suggestion that the solitary large intramuscular dose traditionally given at birth functions as a slow release “depot” store).



You Want to Stick that in my Baby Where!? Informed Consent in Newborn Procedures



Problems from the Vitamin K Injection



Anaphylactic shock due to vitamin K in a newborn and review of literature.
Koklu E, Taskale T, Koklu S, Ariguloglu EA.
J Matern Fetal Neonatal Med. 2013 Oct 17. [Epub ahead of print]

Abstract Newborn infants are born with an immature innate immunity. They are less likely to develop anaphylaxis since their immune system is weaker than older infants and children. There are only a few reports of side effects after vitamin K injection in neonates although prophylaxis against hemorrhagic disease of the newborn with this drug has been in routine practice in all over the world for many years. We herein report a case of anaphylactic shock developing after the intramuscular administration of vitamin K1 in a newborn. To our knowledge, this patient is the first case of neonatal anaphylactic shock developing due to intramuscular administration of vitamin K1. We suggest the clinicians should be aware of this possibility of potentially fatal adverse effect occurring with intramuscular administration of vitamin K1.



Delayed vitamin K deficiency as a cause of bleeding: still a concern in the 21st century!
Kasatkar P, Shetty S, Ghosh K.Blood Coagul Fibrinolysis. 2010 Sep;21(6):608-10. doi: 10.1097/MBC.0b013e32833b645c.

Delayed haemorrhage due to vitamin K deficiency in early infancy has rarely been the cause of acquired hemostatic disorders. We report here 11 cases of vitamin K deficiency bleeding (VKDB), despite receiving appropriate dosage of injectible vitamin K at birth. Bleeding symptoms ranged from excessive bleed from cuts to intracranial bleed. Tuberculosis, diarrhea with intermittent antibiotic therapy were some of the associated symptoms. Laboratory tests confirmed acquired bleeding diathesis due to vitamin K deficiency, which was corrected after adequate vitamin K supplementation. VKDB is not an uncommon phenomenon and should be considered in the differential diagnosis of a child with bleeding diathesis.



Nicolau syndrome induced by intramuscular vitamin K in a premature newborn.

Koklu E, Sarici SU, Altun D, Erdeve O.
Eur J Pediatr. 2009 Dec;168(12):1541-2. doi: 10.1007/s00431-009-0964-6. Epub 2009 Mar 11.


Nicolau syndrome (NS), also known as livedo-like dermatitis or embolia cutis medicamentosa, is a very rare complication of intramuscular and intraarticular injection of various drugs.

We herein report a case of NS developing approximately 2 h after the intramuscular administration of vitamin K1 in an extremely low birth weight premature newborn. To our knowledge, this patient is the youngest case suffering from such a livedoid skin necrosis and the first case of neonatal NS developing due to intramuscular administration of vitamin K1.



Late vitamin K deficiency bleeding after intramuscular prophylaxis at birth: a case report.
Ciantelli M, Bartalena L, Bernardini M, Biver P, Chesi F, Boldrini A, Sigali E.
J Perinatol. 2009 Feb;29(2):168-9. doi: 10.1038/jp.2008.131.


We report the case of a 6-week-old female who presented an intracranial hemorrhage due to late vitamin K deficiency bleeding (VKDB). No other evident bleeding sites were present at the moment of diagnosis. Intramuscular vitamin K (1 mg) was administered at birth. She was exclusively breast-fed. No other risk factors for VKDB were detected. Low levels of vitamin K-dependent coagulation factors and their normalization after vitamin K administration confirmed the diagnosis of late VKDB. The present case suggests potential risks related to a single dose of intramuscular vitamin K at birth.



The Vitamin K Controversy



Summary of Key Points:

Early or "Classic" HDN (also called Vitamin K Deficiency Bleeding) occurs in the first week of life. It is an iatrogenic condition, meaning that it is caused by medical care: Late-onset HDN

Midwife Informed Consent for Vitamin K by Ronnie Falcao, LM MS


High Risks to Your Baby From Vitamin K Shot They Don’t Warn You About

According to Dr. Cees Vermeer, PhD, Associate Professor of Biochemistry at the University of Maastricht (in The Netherlands), the world’s leading specialist in vitamin K, "Vitamin K shots are completely unnecessary for your newborn."


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.


Vitamin K - Excellent Patient Education from Kent Midwifery Practice in the UK (Kay Hardie and Virginia Howes)


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


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

This is an excellent discussion of why a dosage of 20,000 times the normal newborn level of vitamin K is inappropriate for a normal, physiological birth where the baby's umbilical cord is left intact.  She also discusses how vitamin K could disrupt the regulation of cell growth, which might lead to leukemia or other childhood cancers.


An excellent history of the haphazard nature of decisions regarding vitamin K administration and the lack of adequate research.

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


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


From a WHO (World Health Organization) publication--Maternal and newborn health /  Postpartum care of the mother and newborn: a practical guide / 10. Care and service provision in the postpartum period

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.


The push for the Vitamin K - National standard mandates newborn vitamin K injection. Ignorance becomes tacit consent for the questionable neonatal procedure by Don Harkins [Ed: It may be that healthcare providers are required to offer the vitamin K injection, and many don't actually wait for parental consent, but I don't think the injection is technically mandated.]


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 Polycythemia of the Newborn reminds us that increased clottng factors can cause blood clots and decreased tissue oxygenation.  This is especially true with a higher blood plasma volume, as occurs when the cord is left intact for a few minutes after birth and the baby naturally plumps up its circulatory system.

Some very recent studies in The Lancet have associated increased clotting with twice the likelihood of death from bacterial meningitis.  These higher clotting factors may increase the risk from all bacterial infections.  Since the purpose of administration of vitamin K is to increase clotting factors, is it possible that this is also inadvertently increasing a newborn's susceptibility to infection?  [Although no mechanism is proposed for this increased infection rate, it is possible that the decreased tissue oxygenation leaves tissues more susceptible to infection and that this is the cause, rather than the genetic tendency towards clotting?  This would mean that increased clotting from vitamin K would increase susceptibility from this same effect.]

          LONDON (AP) _ Children with a genetic predisposition to produce  high concentrations of a blood-clotting enzyme linked to meningitis  are twice as likely to die from the severe form of that disease as  other children, new research says.

           The findings do not indicate that genetics influence the chances of contracting meningococcal disease, but rather that those who get it are more likely to progress to deadly septic shock.

Genetic basis for meningococcal septic shock - 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


Vitamin K for newborns - why & what risks? - from Danny Tucker's pages


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.


Here are a bunch of links on vit K:

Alternatives to the Vitamin K Shot by Lauren Feder, M.D.

Vitamin K from whale.to

Vitamin K By Karin Rothville DipCBEd.

To Inject or Not by Linda Folden Palmer, DC [Reprinted from International Chiropractic Pediatric Association Newsletter, September/October 2002 Issue]

Improving the Vitamin K Status of Breastfeeding Infants With Maternal Vitamin K Supplements
Frank R. Greer*, Dagger , Sharon P. Marshall§, Andrea L. Foleyparallel , and John W. SuttieDagger , parallel
PEDIATRICS Vol. 99 No. 1 January 1997, pp. 88-92

Routine administration of vitamin K to newborns
A joint position statement of the Fetus and Newborn Committee, Canadian Paediatric Society (CPS),
and the Committee on Child and Adolescent Health, College of Family Physicians of Canada
Paediatr Child Health 1997;2(6):429-31

Here is an excerpt from it that gives oral dosing instructions (for the baby):

"For newborn infants whose parents refuse an intramuscular injection, the physician should recommend an oral dose of 2.0 mg vitamin K1 at the time of the first feeding. (A minority of committee members believe that physicians should have the option to recommend oral administration of vitamin K for newborns under their care.) Use of the parenteral form of vitamin K for oral administration is all that is currently available. This should be repeated at two to four weeks and six to eight weeks of age. Parents should be advised of the importance of the baby receiving follow-up doses and be cautioned that their infants remain at an increased risk of late HDNB (including the potential for intracranial hemorrhage) using this regimen."


Treatise on Vitamin K


Another Treatise on Vitamin K


Another Long Vitamin K Treatise


General Discussion of Oral Vitamin K instead of Injected Vitamin K


General Discussion about Controversy over Administration of Vitamin K to Newborns


VITAMIN K: CONTROVERSY? WHAT CONTROVERSY?


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.


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.


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

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

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."


[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.


[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.]



Vitamin K Protocols



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.


Vitamin K1 Prophylaxis from British Columbia Reproductive Care Program


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.


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.


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


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. 


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.

Oregon State Law - 333-021-0800 - Search for Administration of Vitamin K to Newborns


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.



Sources of Vitamin K



Oral vitamin K is listed at birthwithlove.com


The Vitamin K forms suitable for newborns are forms of Vitamin K1 (Phytonadione), available in injectable or oral forms: as Mephyton for oral use, or as aquamephyton or konakion for injectable use. Menadione (Vitamin K3) is not recommended for prophylaxis and treatment of hemorrhagic disease of the newborn.


Cascade HealthCare Products carries Mephyton (Oral Vitamin K) in the Professional Products > Supplies > Pharmaceuticals section.


The oral vit K is just 2x the normal injectable but given orally. It is AquaMephyton (Phytonadione, MSD) Aqueous colloidal solution 1 mg per 0.5 ml neonatal concentration.



Phytonadione .... Vitamin K-1

Scientific Botanicals, Inc.
8003 Roosevelt Wy Ne
Seattle, Washington 98115-4225
(206) 527-5521
$18.00 for 1 fl. oz. (500 drops)
Standard dose ... 2 drops (2mg./drop) sublingual at birth
I repeat the dose X 2


Konakion is available over the counter in many European countries; my friend gets it for me in Germany.  I don't think there are any customs issues.


Here in Canada we can order Serax directly thru the pharmacy .  Costs me 80 cents per 1 ml glass vile.  I draw up 0.1ml to get
the 10 mg. doseage (oral or I.M.) and then toss the rest as they are notmulti-use viles.  What a waste....  Oh well.


Or you  might be able to order it through the mail from Weston's in the UK


The pharmacy I called indicated: -there are no oral sources of Vit.K manufactured for sale in Canada; -some take the IM product orally; and -Serax is the trade name for octazipam, a sleeping drug.

I am not a pharmacist, and have not checked this with others.



Supporting Normal Vitamin K Production



It's the bacteria present in fecal matter that colonise the baby's gut and allow it to start producing it's own Vit K, and yes the theory is that if midwives weren't so "clean" it would be easier for babies to become colonised with these bacteria.  I'd also argue that using antibiotics in labour would mean that the baby wouldn't get exposure to the necessary bugs. By virtue of route of delivery c/s babies would also not be exposed to these bacteria and so would be higher risk for bleeding disorders.


Lars Hanson, Immunology of Breast Milk is an excellent book for explaining the importance of avoiding anal wiping and babies needing to be exposed to the maternal gut flora. Babies need this to help colonise their uncolonised gut at birth. This indeed helps them to produce their own vitamin K. Babies just need to be near it an exposed at birth. I heard him speak a few weeks ago and he said that babies are born next to the anus for a reason! Ina May Gaskin talks about avoiding wiping for the other reason. To avoid tensing muscles.



Signs Suggesting Need for Vitamin K



Signs Suggesting Need for Vitamin K:

This list is written by Jennifer Enoch. Midwifery Today. Issue 40.


Vitamin K Administration Without Parental Consent



I have encountered several home birth families whose babies were born completely gently, and who were pressured to have their babies receive Vitamin K as much as one to two months PP.

In the 1986 NAPSAC Summit video Doris Haire gives an excellent explanation of how and why obstetric anesthesia/analgesia causes newborn hemorrhagic conditions. Knowing the historical and current heavy uses of narcotics and forceful delivery techniques (mighty vac, forceps, head pulling etc.) it is my belief that the routine administration of Vitamin K has evolved out of the need to protect newborns from iatrogenic conditions rather than inherent problems of gently born babies. In this sense it is a simple, effective and needed technology, however its risks (jaundice and some types of childhood leukemia--injectable) may not be worthwhile when babies have been born without trauma or drug exposure.


Doris Haire has a wonderful speech recorded on the NAPSAC Summit video of 1986 where she describes infant hemorrhagic conditions being caused by the drugs which are commonly injected in epidurals and spinal anesthesia.  In the speech, she actually reads off of a package insert for bupivicaine, which states that a known risk of giving this drug to pregnant, laboring women is to have brain hemorrhage in the infant.  that is what the package insert stated.


I recently transported a primip with prolonged ROM. Baby was ultimately delivered by section (serious decels) after 4 attempts at vacuum extraction. This couple opted not to have a vitamin K shot for the baby because they feel that the baby's vitamin K levels will be rapidly increasing in the coming week and would not need the shot. The pediatrician "harassed" them and threatened to call child protective services on them if they did not get one because they thought it was a form of child abuse (endangerment of a child). The ped frightened them beyond belief concerning infant hemorrhage which can occur at 4-6 weeks of age.

 




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