MIDIRS Essence > June 2009 > Informed Choice

Vitamin K- the debate and the evidence

Originally posted on Jun 2009

Both new and expectant parents find themselves presented with many choices and decisions; some are pretty straightforward, while others because they are not simply a ‘black or white’ matter, can present more of a dilemma. For this reason, it is imperative that parents have access to reliable and accurate information that they are able to understand and, upon which they are able to base their choices and make informed decisions.

One such choice is whether a woman and her partner consent to their newborn baby receiving vitamin K, either as oral drops into the baby’s mouth, or as an intramuscular injection into the leg.

Vitamin K is an essential factor in the production of several of the substances that are needed to enable our blood to clot when we cut or injure ourselves. It is a fat-soluble substance that occurs naturally in the human body as vitamin K1 (phylloquinone) and vitamin K2 (menaquinone). Vitamin K is absorbed by the gut, so the process of digestion is an important part of its production. Naturally occurring vitamin K (phylloquinone) is found in a wide range of foods including, green leafy vegetables like spinach and lettuce, brassica vegetables such as cabbage, kale and broccoli, as well as wheat bran, cereals, and some fruits – kiwi and banana. It is also found in organ meats, such as liver (which should be avoided in pregnancy and when breastfeeding), cow’s milk and other dairy produce, eggs, soy beans and other soy products, and olive oil.

It is recognised that at birth, the newborn baby has very low levels of vitamin K, which are further depleted during the first few days post birth (Seidelin et al 2001). However, in a very small number of newborn babies, 1:10,000 (McNinch et al 2007), a deficiency in vitamin K results in bleeding. This condition is known as vitamin K deficiency bleeding (VKDB), but also used to be referred to as haemorrhagic disease of the newborn (HDN) (Sutor 2003). It is however, difficult to ascertain the true incidence of VKDB in the UK, because a policy of prophylactic vitamin K has now been in place for over 30 years (Hey 2003b). Where it does occur, the extent of the bleeding, the time of its onset and the site(s) (ie the body organs affected), all dictate the extent of the morbidity and, in severe cases, the mortality associated with this condition.

Current practice is based on the premise that the levels of vitamin K should be increased for the first few weeks of life to offer protection against this disorder by supplementing the vitamin K levels until the baby starts to produce its own stores, which will minimise the risk of the baby developing VKDB (NICE 2006). Since 1998 the Department of Health (DH) has recommended that all newborn babies receive prophylactic vitamin K (Calman and Moores 1998). A Cochrane review compared intramuscular (IM) with oral routes of administration of vitamin K (Puckett & Offringa 2000). Evaluation of eleven randomised controlled trials (RCTs) identified that if administered soon after birth, a single dose of IM vitamin K, compared to a single oral dose, provided higher plasma levels of vitamin K in the first few weeks of life when the risk of VKDB is highest. However, multiple doses of oral vitamin K resulted in higher plasma levels at two weeks and two months than a single IM dose. The current NICE guidelines suggest that a single 1mg intramuscular dose is the most clinically and cost-effective method of administration (NICE 2006). Some parents, however, may find intramuscular administration unacceptable, and, in these cases, oral vitamin K should be offered as an option (NICE 2006).

However, although long-established, the recommendations for prophylactic vitamin K may not necessarily be without associated risk and for this reason, health care professionals in contact with childbearing women and their babies need to be conversant with both the benefits and disadvantages of this guidance. This helps to ensure that women and their partners are offered clear and unambiguous information that enables them to make an informed decision about whether or not their baby receives vitamin K. To compound this further, there remains considerable debate, on an international scale, regarding the use of Vitamin K. Particularly, the route of administration (intramuscular injection or oral) and its application in the management of the preterm baby (Clarke et al 2006).

There are divided opinions about the routine administration of vitamin K and this has resulted in several papers identifying the arguments for and against prophylaxis. Those in favour of routine administration appear to focus on the severity of outcome where VKDB develops and its poor predictability rather than its low incidence in the general population (Calman & Moores 1998, Sutor 2003, NICE 2006). Whereas, those not in favour of routine prophylaxis are concerned that where the baby does not have the risk factors for development of VKDB, they are being exposed to a pharmacological substance that they do not need and that this substance could have harmful effects that negate the benefit of prophylaxis for an apparently rare condition (Kay 2000, Wickham 2000, Hey 2003a, Wickham 2003).

Health care professionals need to be aware of both sides of this debate so that they can assist parents to understand the key issues related to their individual circumstances and offer them support in their decision (Tripp & McNinch 1998, Kay 2000). Parents need to be provided with adequate and reliable information on the risks and benefits of vitamin K prophylaxis, the different routes by which it can be given, and the prevalence and risks of VKDB in the infant. Where parents make an informed decision to decline vitamin K for their baby, they should be offered information on the early warning signs of VKDB, as early recognition can be important in ensuring prompt treatment.

The issues around vitamin K have been a major concern for parents, health professionals and policymakers due to the complex and sometimes conflicting evidence that exists alongside vast variations in health policies and practice (Ansell et al 2001, Ansell et al 2004, Busfield et al 2007). MIDIRS Informed Choice leaflet on vitamin K is a key resource in consumer information provision – its unique style helps to convey, what can sometimes be, quite complex information in a format that is conducive to understanding. Issues covered in the information are: What is vitamin K? Current practice, Prophylactic administration, The natural physiological state, Incidence and risk, Benefit or harm, Supplementation in formula milk, Research findings, Route and dose, Risk factors, Parental choice and Practice issues. As such, I would suggest that it is an essential practice tool that will help you to open up and guide discussions with the women in your care, their partners and family.

References

Ansell P, Roman E, Fear NT et al (2001). Vitamin K policies and midwifery practice: questionnaire survey. BMJ 322(7295):1148-52.

Ansell P, Roman E, Fear NT et al (2004). Vitamin K update: survey of paediatricians in the UK. Br J Midwifery 12(1):38-41.

Busfield A, McNinch A, Tripp J (2007). Neonatal vitamin K prophylaxis in Great Britain and Ireland: the impact of perceived risk and product licensing on effectiveness. Arch Dis Child 92(9):754-8.

Calman K, Moores Y (1998). Vitamin K for newborn babies. London: DH

Clarke P, Mitchell SJ, Sundaram S et al (2006). Vitamin K prophylaxis for preterm infants: a randomized, controlled trial of 3 regimens. Pediatr 118(6): e1657-66.

Hey E (2003a). Vitamin K – can we improve on nature? MIDIRS Midwifery Dig 13(1):7-12.

Hey E (2003b). Vitamin K – what, why, and when. Arch Dis Child Fetal Neonatal Ed 88(2):F80-3.

Kay P (2000). The vitamin K controversy. Birth Gaz 16(2):19-21.

McNinch A, Busfield A, Tripp J (2007). Vitamin K deficiency bleeding in Great Britain and Ireland: British Paediatric Surveillance Unit Surveys 1993-94 and 2001-02. Arch Dis Child 92(9):759-66.

National Institute for Health and Clinical Excellence (2006). Routine postnatal care of women and their babies. London: NICE.

Puckett RM, Offringa M (2000). Prophylactic vitamin K for vitamin K deficiency bleeding in neonates. Cochrane Database of Systematic Reviews, issue 4.

Seidelin J, Pedersen BL, Mogensen TS (2001). Risk management by reporting critical incidents. Vitamin K and ephedrine mix-up at a birthing unit. [Article in Danish] Ugeskr Laeger 163:5365-7.

Sutor AH (2003). New aspects of vitamin K prophylaxis. Semin Thromb Hemost 29(4):373-6.

Tripp J, McNinch AW (1998). The vitamin K debacle: cut the Gordian knot but first do no harm. Arch Dis Child 79(4):295-7.

Wickham S (2000). Vitamin K – a flaw in the blueprint? Midwifery Today 56:39-41.

Wickham S (2003). Vitamin K and the newborn. Surrey: AIMS.

Vicky Carne | Head of Midwifery | MIDIRS

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