Neonatal Haemorrhage and Vitamin K

S.J. Rose, MD, Department of Child Health, University of Aberdeen, Medical School Buildings, Foresterhill, Aberdeen AB9 2ZD (UK) There has been renewed interest in both early and late haemorrhagic disease of the newborn [1]. It is clear, however, that a bleeding diathesis may be the presenting feature of more serious underlying pathology especially if presentation is delayed. We report 3 infants born in a 1-month period presenting as haemorrhagic disease of the newborn. All were breast-fed and none had been given vitamin K. Case 1 This infant was born by normal delivery at 37 weeks weighing 3.02 kg. He was admitted to the Baby Unit aged 3 days with a moderate unconjugated hyperbilirubinaemia (maximum 290μmol/l) which resolved with phototherapy. He was readmitted aged 4 weeks following a small haematemesis. Laboratory results: prothrombin time 265 s (control 12 s), partial thromboplastin time 258 s (control 39 s), thrombin time 10 s (control 7 s). He was treated with fresh frozen plasma and vitamin K and the clotting studies rapidly returned to normal. He was readmitted 2 days after discharge after a vomit which contained altered blood. Clotting studies: prothrombin time 14 s (control 12 s), partial thromboplastin time 55 s (control 39 s), thrombin time 9 s (control 7 s). Further investigations revealed a low alpha1-antitrypsin level (0.56 g/l), confirmed on repeat. His phenotype was subsequently found to be PiZZ. boplastic time 49 s (control 38 s), thrombin time 10 s (control 7 s). Studies before therapy were unavailable due to technical error. She was noted to be mildly icteric and she was found to have a conjugated hyperbilirubinaemia. Further investigations suggested a diagnosis of biliary atresia which was confirmed at laparotomy. Discussion Vitamin K prophylaxis given to all breast-fed infants at birth should prevent haemorrhagic disease of the newborn entirely. There is still, however, debate as to the necessity of this blanket approach [2, 3]. There is certainly no documented evidence to support the claim that early administration of vitamin K is useful in preventing late disease [1,4] and we contend such a claim is at best simplistic and worst potentially dangerous. Serious underlying pathology such as alpha-1-antitrypsin deficiency and biliary atresia can present as a bleeding diathesis and we would argue that late presentation of haemorrhagic disease of the newborn must be a diagnosis of exclusion with underlying pathology sought initially.