Intended for healthcare professionals

Letters

Preventing late bleeding in infants with vitamin K deficiency

BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7126.230 (Published 17 January 1998) Cite this as: BMJ 1998;316:230
  1. Win Tin, Consultant paediatriciana,
  2. Unni Wariyar, Consultant paediatriciana,
  3. Edmund Hey, Reired consultant paediatrician, for the Northern Neonatal Networkb
  1. aSouth Cleveland Hospital, Middlesbrough TS4 3BW
  2. bRoyal Victoria Infirmary, Newcastle upon Tyne NE1 4LP

    Editor-The wisdom of using intramuscular vitamin K has become an issue for debate again. Oral and intramuscular prophylaxis both prevent early bleeding, but oral prophylaxis is poor at eliminating late bleeding (between 8 and 90 days after birth) unless treatment is repeated at intervals (1 2-a finding consistent with evidence that intestinal uptake is improved when babies are offered several small, rather than fewer large, oral doses of vitamin K.3 It is also consistent with the suggestion that intramuscular prophylaxis works not because it bypasses poor intestinal uptake (a problem the new micellar preparation was designed to address) but because it establishes a slowly released “depot” of vitamin K within muscle tissue.4

    Figure1

    Incidence of late vitamin K deficiency bleeding in various population studies using Konakion (phytomenadione) (including cases where treatment was not given as recommended as well as treatment failures). Bars indicate 95% confidence intervals

    Countries with a uniform policy have been able to evaluate their practice, but divergent practice in Britain has made this impossible. However, a relatively uniform policy was adopted in the north of England from the start of 1993. Intramuscular treatment (0.1 mg/kg) was given only to those babies judged not well enough to be offered milk on the first day of life. Other babies were offered 1 mg of an oral preparation of vitamin K at birth. Units tried to ensure that all breast fed babies got a total of 4 mg of vitamin K by mouth, and for 89% this was arranged by giving the mother a supply of 1 mg doses of phytomenadione (Orakay; BMS Laboratories, Beverley) for the baby, to be given at fortnightly intervals after discharge. Only three cases of late bleeding have been identified among the 147 271 babies delivered in the region during 1993-6. One had failed to receive further prophylaxis after discharge; the other two were jaundiced at presentation and later found to have α1 antitrypsin deficiency. All had been entirely breast fed, and all made a complete recovery.

    Making healthcare professionals responsible for oral prophylaxis, and giving all treatment either before discharge or during other healthcare visits, has not reduced the incidence of late vitamin K deficiency bleeding in Europe as much as has a policy that leaves prophylaxis in the hands of the parents. Making this work in Britain has not been made easier, however, by the reluctance of health visitors, on legal advice,5 to encourage the oral use of a product that is widely used orally and parenterally in Europe but for which the manufacturers have obtained a licence to market only for parenteral use in the United Kingdom.

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