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Monday, 13 March 2017

Ummmmm we have a baby....now what? - Vitamin K


I have been told that the very first injection my baby is likely to receive will be a Vitamin K shot and this will be give as soon as she is born.

Ouch, that seems harsh to me.

You mean my baby will go through the stress of labour, and then before she gets a proper cuddle with mum and dad, and a good feed, you are going to jab her with a needle and put foreign substances into her body?

What's this all about???

Not only that, but some mums I have spoken to about this in Thailand weren't even aware this happened to their baby, it is something that is considered standard and often gets done when baby is whisked away for checks and you may only find out about it on the bill.

So in the spirit of GET INFORMED, GIVE TRUE CONSENT I thought this was well worth a google.

I hope to answer the 4 main questions everyone should ask their doctor for every procedure and/or medication:


Why does my baby need this vaccination?
Read below for more information but the answer is probably yes
What are the advantages of this vaccination?
Read below for more information but statistics seem to show that the Vitamin K injection does provide good and effective/best protection from VKDB
What are the disadvantages of this medication, including side effects?
Read below for more information but unless your circumstances have complications the side effects seem minimal
Is there an alternative?
Yes there is, read below to decide if the alternative options work for you
What brand and dosage will they be using?
Probably Konakion ® but read below for more information and check with your healthcare provider
What is the cost?
(to be updated)

What is so important about Vitamin K?

Vitamin K is essential for helping blood clot properly.

In newborns, adequate Vitamin K levels are needed to prevent Vitamin K Deficiency Bleeding (VKDB), which is very rare but can be a life-threatening condition that could cause uncontrolled bleeding, sometimes into the brain.

So think of K for Koagulation (the german spelling!) and you should remember the connection.

Let me summarise what I have learnt in my research.



Firstly it does appear that giving a Vitamin K injection very early (within 24 hours) is a common practice throughout the world and there seems good reason for it, but of course it is still always good to make sure that your doctor explains the procedure, alternatives and costs to you.






Why might my baby need a Vitamin K injection so soon?

There are two main reasons why babies do not have enough Vitamin K in their system.
1) Babies are born with very small amounts of Vitamin K because very little transfers from mum to baby via the placenta
2) Babies don't have enough good bacteria in their intestines to produce it themselves very early on 
Babies levels of Vitamin K are at their lowest 2-3 days after birth and are predicted to not get to adult levels until 6 months of age (technically there are two types of Vitamin K, K1 and K2, but I don't think we need to go into detail about that here, you can find more details about that in the links I referenced throughout this article)

Is Vitamin K Deficiency Bleeding (VKDB) something to really worry about?

Some babies are at increased risk of Haemorrhagic Disease of the Newborn (HDN), also known as Vitamin K Deficiency Bleeding (VKDB), including:


Babies born less than 37 weeks of pregnancy
Babies whose birth involved the use of forceps, ventouse or caesarean, where bruising occurs
Babies who had trouble breathing and did not get enough oxygen when they were born
Babies whose mum are taking anti-convulsants, anti-coagulants, or drugs to treat tuberculosis
Babies who have liver disease that may show as prolonged jaundice or symptoms, such as pale stools or dark urine


According to www.nct.org.uk “this means that about a third of babies are at increased risk”

There are 3 types of Vitamin K Deficiency Bleeding (VKDB):
Early - within 24 hours of birth - its seems that the main cause for this is if mum has been taking some medication that inhibits Vitamin K 
Classic - between 1 and 7 days of birth - it seems this is mostly associated with feeding (insufficient levels of Vitamin K passed to baby) 
Late - between 1 week and 6 months of birth - this is very rare, but can lead to neurological damage and is the one that everyone is worried about
Worst case scenario – Late VKDB:
According to Evidence Based Birth statistics shows that:

“When infants do not receive any Vitamin K at birth, statistics from Europe show that 4.4 to 10.5 infants out of 100,000 will develop late VKDB. Rates are higher in Asian countries (1 out of every 6,000 infants).”

“When infants receive oral Vitamin K at least three times during infancy (typically at birth, one week, and four weeks), anywhere from 1.4 to 6.4 infants out of 100,000 will develop late VKDB.”

“When infants receive the Vitamin K shot at birth, anywhere from 0 to 0.62 infants per 100,000 have VKDB. In an 18 year period in the United Kingdom, only two babies who received the shot had late VKDB brain bleeds, out of 64 million births

Overall, I think we can safely say that late VKDB appears to be very rare in Europe, but may be more common in some Asian countries, such as Japan, Vietnam, and Thailand.

According to Evidence Based Birth, in the 1980's infants in Thailand did not receive any Vitamin K at birth and at that time, researchers reported that 72 out of 100,000 infants developed late VKDB. It is assumed that the variance between countries may be due to a combination of environment (diet) and genetics.

Although late VKDB is rare, the consequences may be great.

According to reseachers, and discussed in Evidence Based Birth, more than half of infants who develop late VKDB will have bleeding in the brain and the mortality rate for late VKDB is approximately 20%.

Specialists advise that the symptoms can be subtle and therefore parents may not seek medical help quickly enough. The key symptoms are:

difficulty feeding
lethargy
fussiness


Hmmm sounds just like a normal day with a new baby, I see the difficulty here!

What about Classic VKDB? Is that dangerous?

Classic VKDB—bleeding that occurs in the first week of life—is more common than Late VKDB, depending on the study you read this ranges from 0-1.5% of newborns will experience Classic VKDB if they don’t receive Vitamin K at birth.

But, Classic VKDB is usually mild and may only involve bleeding at the umbilical cord site or circumcision site (of course every case may be different).

But we can safely say that the mortality rate of classical VKDB is very low in developed countries. Of course lack of medical resources or delay in treatment is the most contributing factor in developing countries (Lippi & Franchini, 2011).

Are there any disadvantages, or side effects, of the injection?

Some parents are worried about whether there are toxins in injections. You can try to alleviate some concern by asking if they can administer a preservative free version of the injection (to date I cannot confirm if one is available in Thailand)

Typical Ingredients (may vary depending on manufacturer) www.dailymed.nlm.nih.gov:
2 mg Phytondione
70 mgs polyoxyethylated fatty acid
37.5 mgs hydrous dextrose
9 mg benzyl alcohol
hydrochloric acid (not always)

Or a preservative free version has typical ingredients (may vary depending on manufacturer) Evidence Based Birth:
1 mg Vitamin K1
10 mg Polysorbate 80
10.4 mg Propylene glycol
0.17 mg Sodium acetqate anhydrous
0.00002 ml Glacial acetic acid, also known as vinegar

Other concerns you may have heard about:

Propylene Glycol: According to Evidence Based Birth “Proplyene Glycol is used in many medications (oral, topical, and injections) because it is a very good at helping medications absorb into liquid. Any cases about severe side effects from propylene glycol are from decades ago, and were related to very high doses….”

Leukaemia/Cancer: You may have heard about suggestions that vitamin K injections were associated with cancer and leukemia. However, researchers have come to the conclusion that there is no evidence supporting a relationship between Vitamin K and leukemia or other childhood cancers (Shearer, 2009).There is NO known association between the two and many many researchers concur on this.

Benzyl alcohol: manufactured vitamin K may contain benzyl alcohol. Benzyl alcohol targets the liver, the organ which is necessary for humans detoxify. This may be associated with babies developing jaundice (hyperbilirubinemia) www.thevaccinereaction.org Benzyl alcohol has also been reported to be associated with a fatal "Gasping Syndrome" in premature infants www.drugs.com

Aluminum (which may be in some versions): Aluminum may reach toxic levels with prolonged parenteral administration if kidney function is impaired. Premature neonates are particularly at risk because their kidneys are immature, and they required large amounts of calcium and phosphate solutions, which contain aluminum. www.drugs.com 

Allergic reactions: According to Evidence Based Birth “almost all of the cases in history occurred with the intravenous (IV) form, something that is never used in the newborn period unless an infant comes in with vitamin K deficiency bleeding….”

Side effects: 
According to Evidence Based Birth side effects “from vitamin K injection given at birth are incredibly rare….”

Of course there is always the case that any injection could lead to redness or irritation, and we can’t say for sure how much pain a baby feels with an injection, but all of this can be minimized as much as possible by mothers (or nurses) intervention and calming influence. Consider having the injection administered whilst conducting skin to skin and/or breastfeeding for example.

Are there any alternatives?

Can I help by breast feeding?

People can be forgiven for thinking that surely there is an easy solution – surely if mum has good Vitamin K levels and she breastfeeds that would be OK???!!!

Unfortunately it isn’t that simple.

Even with the best intentions and diets, most adults do not have enough Vitamin K in their system to provide the adequate dose to their baby www.ncbi.nlm.nih.gov.

Breastmilk today is not normally good enough, on its own, to provide enough Vitamin K. In fact, virtually all babies with late VKDB are exclusively breastfed (Evidence Based Birth).

Breast milk has very tiny amounts of Vitamin K. Colostrum has about 2 micrograms of Vitamin K per Liter, while mature milk has 1 microgram per Liter (von Kries et al, 1987).

But can I boost this with supplements taken by the mother?

According to Evidence Based Birth “so far, the studies that have been done looked at babies in which both the babies AND their mothers received supplements. No research has been done on maternal supplementation alone, probably for ethical reasons. It appears that when the mother takes 5 mg of Vitamin K per day, that this is very effective in raising levels of Vitamin K in breast milk, and probably raises Vitamin K levels in the baby….”

A knock on from this question is what about formula fed babies? - it does transpire, in the particular instance of VKDB, that formula fed babies are better off. According to Evidence Based Birth there are virtually no reports of VKDB occurring in infants who are formula fed.

“This is because, in contrast to breast milk, formula has relatively high levels of Vitamin K1—55 micrograms per liter (Shearer 2009). On average, babies who are fed formula receive nearly 100 times more Vitamin K1 than babies who are breastfed....

So if you are planning to exclusively formula feed your baby from birth, you may decide that an injection is not necessary, but I always suggest speaking to healthcare provider before making any final decisions.

Is there a supplement that I can give to my baby orally?

Yes there is, and there are different oral regimes that are followed in different countries, each with varying results depending on the research. 

The US doesn’t have an approved FDA Oral Vitamin K, although people talk about the availability of K-Quinone (Scientific Botanicals, Inc) online. 

Other countries like Germany, Netherlands and Denmark have oral regimes for Vitamin K, but according to Evidence Based Birth the cons may outweigh the pros, especially if there are liver or gallbladder complications. 

In the UK www.nhs.uk you should be able to ask for an oral regime (probably the 3 dose regime) as an option also www.uhcw.nhs.uk (PDF doc)

So what does it all come down to – what should I do???


Evidence Based Birth published this Pro’s and Con’s list taken from the Cochrane review (Puckett and Offering, 2000)

Injection versus Oral

What are the pros of a Vitamin K injection?
Is highly effective at preventing Classic and Late VKDB

Vitamin K is slowly released over time from the injection site, which provides enough Vitamin K1 until the baby’s Vitamin K levels reach adult levels naturally

What are the cons of a Vitamin K injection?
Causes pain, which can be minimized by having the infant breastfeed while the shot is given

Can cause bleeding or bruising at the injection site

What are the pros of oral Vitamin K?
Easy to give and not invasive

The 3-dose regimen lowers the risk of Classic and Late VKDB, but not as well as the injection
The weekly regimen seems to protect infants with undiagnosed gallbladder problems just as well as the shot does

What are the cons of oral Vitamin K?
Some babies may not be able to absorb it, or they may spit it up

If the baby has undetected gallbladder or liver disease, a 3-dose regimen of oral Vitamin K will not protect them from VKDB
The 3-dose regimen is less effective than the shot at preventing Late VKDB
Requires that parents commit to giving at least three doses or weekly dose

What brand and dosage do they use in Thailand?

Vitamin K1 injections are made under several brand names:

Phylloquinone ®
Phytonadione ®
AquaMEPHYTON ®
Mephyton ®
Konakion ®

From my research, discussions with other mums, and discussions with healthcare professionals in Thailand I can advise that in Samitivej it is common to administer Konakion brand (please note this is also used i the UK) I will release an update to this post when I find out more from other hospitals.

It is believed that this brand does not contain Aluminium. See here for more information www.medicines.org.uk

According to Evidence Based Birth  “depending on the country in which Vitamin K is administered, there are 1 to 2 mg of Vitamin K1 in the injection….Although this amount may seem high to some, it is thought that the Vitamin K1 injection is temporarily stored in the leg muscle and gradually released into the baby’s system over the next several months. This kind of delayed-release explains why the shot protects babies from both Classic AND Late Vitamin K deficiency bleeding (Loughnan and McDougall 1996).”  

According to www.medicines.org.uk the dosage for Konakian in healthy neonates of 36 weeks or older can be either 1mg administered by intramuscular injection (at birth or soon after birth) or 2mg administered orally, followed by 2mg at 4-7 days and a further 2mg at 1 month (if exclusively formula fed they say you may be able to omit the third dose)

I understand that oral Vitamin K is available in Thailand, if you cannot obtain this from your Doctor I suggest you speak to the Doula community in Thailand if you need help with this (Websites I Find Useful)

What is the cost?

I will release an update to this post as soon as I have more information about cost

Conclusion

I am going to directly quote someone much more qualified than me on this. Alice Callahan - trained as a research scientist and has a PhD in nutrition. She's the author of The Science of Mom: A Research-Based Guide to Your Baby's First Year, published by John Hopkins University Press 2015 

"This is an evidence-based recommendation. The shot is safe and effective. Of all the many questions that I researched for my book, this one was one of the few that had a crystal clear answer. There's just no good reason to decline the vitamin K shot and leave your newborn at risk of VKDB."

Of course, if you feel you have good reason to use the oral method, and are confident in the brand, dosage and your ability to administer as prescribed (without forgetting) then this is an option.

Me: I will be including the Vitamin K injection in my birth plan, especially as I take very small amounts of aspirin which could prevent clotting, and to ease my worries of it causing any stress to our new bundle I will be requesting that it is administered during "skin to skin" time.


Sources:

3 comments:

  1. Thanks for this detailed information! I took vitamin K supplements during my pregnancy and nursing time. Additionally I supportet with combiotic formula from myorganicformula.com/hipp-combiotic, which contains vitamin K and other vitamine.

    Greetingy, Emilia

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    Replies
    1. Thanks Emilia. It's always great to know ways to help boost our systems, especially when we can feel so drained at such an important time. Thanks for sharing :-)

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