What is Hemorrhagic Disease of Newborn?
Hemorrhagic disorder of the newborn is a type of bleeding problem that can show up in the first few weeks after a baby is born. This term includes all bleeding conditions, such as those caused by a lack of vitamin K, injury, or not having enough clotting proteins, among others. If the disorder is due to a lack of vitamin K, it is specifically known as vitamin K deficiency bleeding or VKDB.
Vitamin K is a fat-dissolving vitamin that is mainly processed by bacteria in an adult’s gut. But newborns have very little vitamin K stored in their liver when they are born, and they can’t create vitamin K themselves because their gut is free of bacteria. This is why they might get hemorrhagic disease. One of the main jobs of vitamin K is to activate proteins involved in blood clotting. If there is not enough vitamin K, these proteins can’t do their job, and this can lead to bleeding.
Hemorrhagic disorder of the newborn can be grouped into three categories based on when it starts.
1. Early: It happens within the first 24 hours after birth, and can even start while the baby is still in the womb or during labor.
2. Classical: It takes place within the first week of a baby’s life (from the 2nd to the 7th day).
3. Late: It starts from the 8th day and can continue up to 6-12 months.
What Causes Hemorrhagic Disease of Newborn?
Vitamin K deficiency can occur without a known reason, also known as idiopathic, or it can be secondary to other health conditions. The reason behind idiopathic causes is unknown, but some secondary causes have been studied. When someone has a Vitamin K deficiency, their clotting factors, which help their blood to clot, can’t work as well. This can lead to a condition known as hemorrhagic disease of the newborn.
Adults can produce Vitamin K in their large intestine with the help of gut bacteria. However, newborns have lower levels of Vitamin K because they get a limited amount from the placenta and their gut doesn’t yet create enough Vitamin K. Additionally, the amount of Vitamin K found in breast milk is low, and babies have limited capacity to store it in their liver.
Babies born to mothers who are on specific drugs for tuberculosis (like isoniazid and rifampicin), epilepsy (like phenytoin, barbiturates, and carbamazepine), broad-spectrum antibiotics (like cephalosporins), or drugs that work against Vitamin K like warfarin, can be at risk for Vitamin K deficiency.
Also, Infants diagnosed with malabsorption diseases, like cystic fibrosis, or liver and biliary disorders like biliary atresia, have been found to develop Vitamin K deficiency. Certain gene mutations that affect the production of specific enzymes, gamma-glutamyl carboxylase and epoxide reductase, have also been linked to Vitamin K deficiency.
Risk Factors and Frequency for Hemorrhagic Disease of Newborn
Vitamin K deficiency bleeding, also known as VKDB, can affect all newborn babies, regardless of their race, sex, color, religion, or where they come from. However, studies have found that VKDB might be more common in male babies, those who are breastfed, and those who were born naturally without a medical procedure.
- Among infants who didn’t get a preventative vitamin K treatment, early VKDB happens in about 6% to 12% of cases.
- Classic VKDB used to occur in 0.25% to 1.5% of infants, but recent improvements in newborn care, including routine vitamin K treatments, have reduced this to between 0.01% and 0.44% of infants.
- Late VKDB is rarer, happening in 1 out of every 15,000 to 20,000 births. It’s mainly seen in babies who are only breastfed, or those with conditions that make it hard for their bodies to take in vitamin K properly.
- A common symptom of late VKDB is bleeding in the brain, which can be very serious. This can lead to death in 20% to 50% of babies, and can cause ongoing health problems in others.
Signs and Symptoms of Hemorrhagic Disease of Newborn
Vitamin K deficiency bleeding (VKDB) is a serious condition that healthcare providers need to be aware of. Some important things to consider if VKDB is suspected are:
- Medications taken during pregnancy such as anticonvulsants, anti-tubercular drugs, warfarin, salicylates, etc.
- Gestation period, as premature babies have a higher likelihood of VKDB.
- Feeding method – breastfed or bottle-fed, as bottle-fed infants usually get more essential vitamins and minerals from fortified formulas and therefore have lower risk.
- Delivery place, notably home births where immediate vitamin K might not be accessible, thus raising the risk.
Patients with VKDB could show some physical symptoms including:
- Bleeding under the skin of the scalp (cephalhematoma)
- Bleeding within the skull (intracranial)
- Chest bleeding that could cause blood in coughed up mucus (hemoptysis) and breathing distress
- Internal abdominal bleeding that could lead to bloody stool (melena) or bloody vomiting (hematemesis)
- Bleeding from the skin showing small, round spots (petechiae)
- Bleeding from the gums, nose, or other mucous membranes
- Bleeding after circumcision
- Bleeding from the belly button (umbilical stump) after birth
- Bleeding at vaccination site
If the VKDB is late onset, the baby might show symptoms like being unresponsive (floppy), lethargy, feeding difficulties, a bulging soft spot on the head (fontanelles), decreased breathing rate, altered consciousness, seizures, or paleness.
Testing for Hemorrhagic Disease of Newborn
Your doctor will use different methods to find out what’s happening to you. These include your medical history, a physical exam, lab tests, and scans or X-rays. Together, these tools help doctors figure out what’s wrong and how to treat it.
There are several lab tests that are often recommended:
1. A complete blood count: This test checks the levels of different types of cells in your blood. In your case, they’ll check whether your platelet levels are within the normal range of 1.5 to 4 lakhs per cubic millimeter. Platelets are tiny blood cells that help your body form clots to stop bleeding.
2. Clotting profile: This set of tests measures how well your blood is clotting. It’ll include tests for International Normalized Ratio (INR), Prothrombin Time (PT), Partial Thromboplastin Time (PTT), clotting time, and fibrinogen levels. If these results are above normal, it suggests that your blood is not clotting as it should. This may be due to factors like decreased clotting factors, which are proteins in the blood that help control bleeding. However, your fibrinogen (a protein in your blood that helps it clot) levels will probably stay normal.
3. Estimating Protein Induced by Vitamin K Antagonist (PIVKA): PIVKA are proteins that show up when there is a lack of vitamin K in your body. Vitamin K is crucial for the production of certain proteins that help your blood to clot properly. PIVKA levels are evaluated using advanced lab tests like High-Pressure Liquid Chromatography (HPLC), Enzyme-Linked Immunosorbent Assay (ELISA), or Immuno-Electrophoresis. The presence of any amount of PIVKA is a sign of vitamin K deficiency. Fortunately, it usually goes away around the fifth day of taking vitamin K.
4. Chest X-ray or ultrasound: These tools help check if there’s any bleeding inside body cavities, like your chest or stomach.
5. CT and MRI Scans: These advanced scans help doctors check for any bleeding inside your skull.
Treatment Options for Hemorrhagic Disease of Newborn
The main way to treat Vitamin K Deficiency Bleeding (VKDB) is by quickly giving the infant vitamin K and then investigating the cause of the disease.
In serious cases where the baby is at risk and bleeding heavily, immediate blood transfusions can be given. Fresh frozen plasma, which is a blood product that helps with clotting, may also be administered to control the bleeding.
Vitamin K Deficiency Bleeding can sometimes lead to brain hemorrhage. This is when bleeding occurs in the spaces surrounding the brain. The most common type is subdural hemorrhage, which might need surgery or a procedure called intracranial shunting. This procedure helps relieve the buildup of pressure in the brain and related symptoms.
Despite treatment, babies with late-stage VKDB might still show abnormal brain function. These babies will need regular monitoring and follow-ups. Physiotherapy may be recommended to preserve or strengthen brain function. If a baby has difficulty in sucking or swallowing, they may need help with feeding.
Nevertheless, giving a single injection of 1 mg of vitamin K into the muscle is known to help with blood clotting between 1 to 7 days.
It’s important to note that babies who didn’t get VKDB prevention treatment might have an undiagnosed liver disease.
What else can Hemorrhagic Disease of Newborn be?
When it comes to diagnosing VKDB, a type of bleeding disorder, doctors have to consider other conditions that might be causing the symptoms. These conditions may include:
- Injury, either unintentional or intentional harm.
- Deficiencies in clotting factors like hemophilia A or B. If the condition doesn’t improve after clotting factors are given, it can help identify the real cause.
- Disseminated intravascular coagulation (DIC), a condition that affects the blood’s ability to clot. Lab tests can help distinguish between DIC and VKDB.
- Thrombocytopenia, especially when caused by the mother’s immune system. In this case, antibodies can cross the placenta and reduce the baby’s platelet count, causing bruising. But in VKDB, the platelet count is usually normal.
- In infants who have isolated gastrointestinal bleeding, intussusception could be a cause.
By conducting appropriate laboratory studies, it becomes easier for doctors to make a correct diagnosis and determine the best treatment plan.
What to expect with Hemorrhagic Disease of Newborn
Giving newborns vitamin K at birth has been shown to greatly improve their chances of survival and decrease the risk of death. Newborns who experience a condition called intracranial hemorrhage, a bleeding inside the brain, could suffer from neurological damage. However, the introduction of vitamin K has lessened the occurrence of a disease called “hemorrhagic disease of the newborn,” which is characterized by bleeding problems. Therefore, the continued use of vitamin K as a preventive measure is very effective and should be carried on.
Possible Complications When Diagnosed with Hemorrhagic Disease of Newborn
The primary risk associated with newborns suffering from hemorrhagic disease is bleeding. This bleeding could be severe and even cause life-threatening conditions in infants. In fact, this disease is a major factor that can lead to intracranial hemorrhage, that is, bleeding in the brain within an infant’s first year of life.
Vitamin K deficiency that presents later on in life is generally associated with health problems. These problems often show themselves with neurological deficits, or difficulties with the nervous system. These may include hydrocephalus (water on the brain), encephalopathy (brain diseases, damage, or malfunction), cerebral atrophy (brain wasting), seizures, and serious developmental delays.
Adverse Effects:
- Baby’s life can be at risk due to severe bleeding
- Can cause intracranial hemorrhage (bleeding in the brain)
- Neurological problems due to late presenting vitamin K deficiency
- Conditions such as hydrocephalus (water on the brain)
- Encephalopathy (brain diseases, damage, or malfunction)
- Cerebral atrophy (brain wasting)
- Seizures
- Serious developmental delay
Preventing Hemorrhagic Disease of Newborn
Healthcare professionals need to work hand in hand with parents to stress the importance of vitamin K treatment and the seriousness of the related illness. They should clearly communicate the advantages of administering vitamin K through injections. If parents are averse to the injection, the potential harmful effects of not getting enough vitamin K should be discussed. As an alternative, health professionals might recommend an oral dosage of 2 mg of vitamin K. It is also suggested that this dosage be repeated when the baby is around 2-4 weeks and again at 6-8 weeks old.