Vitamin K Deficiency Bleeding (VKDB)

Dr Rajesh Kumar MD (PGI), DM (Neonatology) PGI, Chandigarh, India Rani Children Hospital, Ranchi

3 months old child Fever 2 days, extreme irritability 1 day, bulging AF CT head done Prolonged PT and PTTK Corrected after Vit K and Plasma

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

11 months, 10.8 kg, OFC: 45.5 cm, sitting +, Stands with support

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Early HDN
40 wks, term baby born NVD, had h/o seizure on phenobarbitone Baby had cephalhematoma, was hypotonic, Vit K was given USG head showed ICH Lab report :PT, PTTK increased

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Vitamin K Deficiency
Incomplete carboxylation of coagulation proteins that do not form appropriate complexes with Ca&phospholip

Qualitative deficiency of Factors II,VII,IX,X

BLEEDING
07/03/07 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Conditions associated with Vit K Bleeding

Hemorrhagic deficiency of newborn & infants(VKDB) Chronic diarrhoeas & malabsorption Liver disorders-hepatitis Warfarin and other drugs Prolonged antibiotics

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

History
Haemorrhagic disease of newborn: Townsend 1894 Dam et al 1952: Parenteral vit K prevents Hgic disaese in newborn (n= 33,000) VKDB: Committee of the International Society on Thrombosis and Hemostasis in 1999 Method of prophylaxis: ?
07/03/07 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Case selection criteria

1. Age 2 days to 12 months 2. Prolonged PT(>1.5 times) & PTTK

3. Which normalised within 24 hrs of Vit

K 4. Absence of liver disease and/or septicemia

07/03/07 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Age distribution in VKDB

0-1 days..nil 1-6 days..12.5% 7-30 days27.5% 1-3 mths..32.5% 3-6 mths..07.5% 6-9 mths..10% 9-12 mths7.5% >12 mths.2.5%
07/03/07 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Late VKDB
Incidence: 4.4 7.2 per lac With IM prophylaxis: 1.4 6.4 per lac

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Why is newborn Vit K deficient?

Maternal:cord blood ratio30:1 Hepatic content in neonate-25% of adult Human milk content(2-15ug/l)-25% cowmilk Colostrum rich in Vit K not given Sterile gut Plasma half-life-72 hrs
07/03/07 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Limited placental transfer of Vit K; 30-60 % of adult value at birth Breast fed will have adult value by 6 weeks Formula fed has much higher value; 10 fold Lipid soluble Phytonadion (1 mg) injection at birth: Vit K level at 6 wks 1.5 times higher than breast fed babies
07/03/07 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Pregnant mothers
Tablets of vit k 20mg/day in the last month of pregnancy--Improve blood levels of newborn Improve Vit K content of breast milk Esp. in mothers taking medications Must be given routinely

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

What are the Forms of Vitamin K?

Refers to a group of 2-methyl-1,4naphthoquinone derivatives which can fulfill an essential co-factor function in humans in the biosynthesis of a number of calcium-binding proteins, some of which are essential for haemostasis. In nature,
vitamin K occurs as phylloquinone in plants menaquinones produced by bacteria.

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Vitamin K1
Phylloquinone: found in dairy products, green vegetables, and vegetable oils, is an aqueous, colloidal solution of vitamin K1.
Phytomenadione Phytonadione Phytylmenadione 3-Phytylmenadione Phytylmenaquinone

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Vitamine K2
Menaquinone, which is synthesized by gut flora.
Menatetrenone MK4 Vitamin K2(20) Vitamin MK4

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Vitamine K 3
Menadione: It is a synthetic, water soluble form that is no longer used medically because of its ability to produce hemolytic anemia.
Menadione Menadione sodium bisulfite Menadiol Menadiol sodium phosphate Menadiol sodium phosphate hexahydrate

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Vitamine K 4
Acetomenaphthone

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Kaplin: Acetomenaphthone K-NAT: Vitamin K3, IM / IV (slow IV), Concerns about hemolytic anemia Kenadion: Vitamin K1, IM / IV (slow IV)

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Vit K by IV route

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Dose of Vit K1

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Treatment of VKDB?

Vit K should be administered subcutaneously or intravenously but not intramuscularly to avoid hematoma formation at the site of injection Plasma should be administered to infants with serious bleeding manifestations.

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Vit K prophylaxis

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Vit K prophylaxis

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Vit K prophylaxis
I.M. Vit K at birth Oral mixed miclellar Vit K (Konakion): 2 mg at birth, 7 days, 30 days ( many failures) Weekly oral Vit K (2 mg) for 3 months Oral 2 mg at birth, 25 mcg daily from 7 days to 3 months

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Vitamin K1 should be given to all newborns as a single, intramuscular dose of 0.5 to 1 mg. Additional research should be conducted on the efficacy, safety, and bioavailability of oral formulations and optimal dosing regimens of vitamin K to prevent late VKDB. Health care professionals should promote awareness among families of the risks of late VKDB associated with inadequate vitamin K prophylaxis from current oral dosage regimens, particularly for newborns who are breastfed exclusively.

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Oral Vit K1
Efficacy in oral administration is uncertain Oral administration contraindicated in
Premature, sick neonate, on antibiotic Cholestasis, diarrhea

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

For 5 kg baby with cholestasis

Drops ABDEC: Drops EVION: Vit K:

1 ml TDS 1 -2 ml TDS

Kenadion 10: ampoule EOD Inj Kenadion 1 once weekly

Syp CALCIMAX: 5 ml TDS (Vit D 1800 IU) ? CALCIROL Sachet:

07/03/07 Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

3 ml ABDEC
Vit A: Vit D:

15000 IU 1200 IU
3000 IU 1200 IU

3 ml VISYNERAL Z
Vit A: Vit D:

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)

Evion drops: upto 10 ml per day UDCA (150 mg): 1 tab per day Syp Phenobarb: 6 ml per day Vit D: 5000- 8000 IU per day Vit A: 10,000 15000 per day

07/03/07

Dr Rajesh Kumar, MD (PGI, Chandigarh), DM (Neonatology, PGI, Chandigarh)