Hemorrhagic disease of the newborn is a bleeding disorder that occurs during the first few days of a newborn’s life. The condition happens due to vitamin K deficiency and is also called vitamin K deficiency bleeding (VKDB). Babies are usually born with low body reserves of vitamin K, which is essential for blood clotting.
Read this post to know more about the types, causes, signs, diagnosis, complications, treatment, and outcomes of VKDB or hemorrhagic disease of the newborn.
Types Of VKDB In Newborns
According to the age of onset, hemorrhagic disease of the newborns can be classified into three types(1).
- Early VKDB occurs in-utero, during delivery, or during the first 24 hours after birth
- Classical VKDB occurs from the second to the seventh day of neonatal life (first week of life)
- Late VKDB occurs any time from the eighth day to six to twelve months after birth.
Causes Of Hemorrhagic Disease Of The Newborn
A deficiency of vitamin K causes the reduced activity of clotting factors, leading to bleeding. This condition is called hemorrhagic disease of the newborn or VKDB.
The causes of vitamin K deficiency could be idiopathic or secondary. The idiopathic causes are unknown causes. The secondary causes of vitamin K deficiency could include the following (2).
- Insufficient placental transfer of vitamin K
- Poor hepatic storage
- A sterile gut that cannot synthesize vitamin K
Adults can synthesize vitamin K in the gut with the help of gut bacteria. In comparison, the neonatal gut may lack bacteria that can make vitamin K.
Risk Factors For Hemorrhagic Disease Of The Newborn
The following factors may increase the risk of developing vitamin K deficiency in a newborn(3).
- Malabsorption diseases, such as cystic fibrosis
- Mutation in genes that encode enzymes for the formation of vitamin K
- Maternal exposure to anti-tuberculosis drugs
- Maternal exposure to anti-epileptic drugs and broad-spectrum antibiotics
- Maternal use of warfarin, an anti-coagulant drug and vitamin K antagonist
Some of the other risk factors for infants include being born through spontaneous vaginal delivery, breastfeeding, and male gender. It is not fully understood how these risk factors lead to vitamin K deficiency among infants.
Symptoms And Signs Of Hemorrhagic Disease
The following signs and symptoms are commonly seen in VKDB (1).
- Intracranial bleeding(bleeding inside the skull)
- Cephalohematoma(bleeding outside the skull)
- Hemoptysis (coughing up blood)
- Respiratory distress
- Melaena (black tarry stools)
- Hematemesis (vomiting blood)
- Petechiae or red spots on the skin
- Bleeding from the gums
- Nasal bleeding
- Bleeding from vaccination sites
- Bleeding from the umbilical cord after cutting the cord
Respiratory symptoms indicate bleeding in the intrathoracic areas, while GI symptoms, such as black tarry stools, indicate bleeding from the GI tract. Intracranial bleeding is common in babies with VKDB, and they may have the following signs and symptoms (1).
- Floppiness
- Bulging fontanelles(soft spots)
- Reduced consciousness
- Pallor (paleness of skin)
- Feeding problems
- Reduced respiratory rate
Seek emergency medical care if you notice any signs of bleeding in the newborn. Delay in treatment may lead to complications.
Possible Complications Of Hemorrhagic Disease
Bleeding is the most common complication in VKDB. It can lead to intracranial hemorrhage, which is often fatal among babies younger than a year. Intracranial hemorrhage and increased intracranial pressure could also lead to the following neurological conditions (4).
- Cerebral atrophy
- Severe developmental delay
- Encephalopathy
- Hydrocephalus
Complications are expected in late vitamin K deficiency bleeding. Therefore, if you notice any unusual bleeding or other signs, seek immediate pediatric care.
Diagnosis Of Hemorrhagic Disease Of The Newborn
Doctors may ask for detailed prenatal and medical history to find the cause of vitamin K deficiency. The following tests are ordered to diagnose the condition and its cause (1).
- Partial thromboplastin time (PTT)
- Complete blood count to analyze platelet levels
- Prothrombin time (PT)
- International normalized ratio (INR)
- Fibrinogen levels
- Estimation of PIVKA, a protein induced in vitamin K absence
- Chest X-ray and ultrasound to look for bleeding in the body
- MRI or CT scan to visualize intracranial hemorrhage
The following diseases are differentiated before diagnosing VKDB, depending on the signs and symptoms.
- Hemophilia or hemophilia B, a non-reversal clotting factor deficiency
- Disseminated intravascular coagulation (DIC)
- Thrombocytopenia (low platelet count)
- Gastrointestinal bleeding due to conditions such as intussusception
Vitamin K deficiency causes an increase in the clotting time, while the fibrinogen levels remain normal. Even if the cause of VKDB is not determined, the administration of vitamin K for five days could improve clotting time, thus letting doctors conclude the presence of VKDB.
Treatment For Hemorrhagic Disease Of The Newborn
The treatment of vitamin k deficiency is the administration of vitamin K to the newborn. Usually, the treatment begins with the investigation of the cause. Therefore, the infant is administered vitamin K even before the diagnosis of the underlying cause.
A single intramuscular dose of 1mg vitamin K can improve the condition within a week. Management may vary depending on the symptoms and severity of bleeding (5).
- Immediate blood transfusion with fresh frozen plasma is needed for a newborn with life-threatening bleeding.
- Intracranial shunting is done to relieve intracranial pressure.
- Physiotherapy may be referred for neurological strengthening.
- Nutritional assistance is provided for babies with swallowing and sucking difficulties.
Prognosis Of Hemorrhagic Disease Of The Newborn
The prognosis (outcome) of the disease is improved in babies who receive timely administration of vitamin K.Itmay even help reduce morbidities and mortalities due to bleeding. Neurological damage could be a long-term outcome for babies who had VKDB at an early age. However, early medical care and vitamin K injections could help prevent it. The baby could continue to require routine follows up to reduce the risk of complications.
The American Academy of Pediatrics recommends giving the baby a shot of vitamin K immediately after birth to prevent the onset of hemorrhagic disease. This practice has significantly reduced the occurrence of the condition. If you are expecting a baby, you may ask about the vitamin K injection at your chosen hospital or maternity clinic. Some studies indicate that formula-fed babies are less likely to develop a deficiency of vitamin K. If your baby already has VKDB or is at risk of developing it, discuss the option of feeding formula with your baby’s pediatrician.