Breastmilk, PCBs, Dioxins and Vitamin K Deficiency: Discussion Paper

In this paper the hypothesis is discussed that polychlorinated biphenyls (PCBs),polychlorinated dibenzop-dioxines (PCDDs)and polychlorinated dibenzofurans (PCDFs) present in breastmilk in industrial countries cause the late haemorrhagic disease ofthe newborn. Late haemorrhagic disease in the newborn (HDN) is a rather new disease entity described as such in 1985 by Lane-, He starts his description with the following sentence 'During the past ten years it has become apparent that vitamin K deficiency hemorrhage is an important cause of morbidity and mortality in infants older than 1 month'. He differentiates the disease into three periods: (1) The early form: 0-24 h after birth; (2) the classic form: 1-7 days after birth; (3) the late form: 1-3 months after birth. The classic form and the early form are described by van Creveld in 1957 and he emphasizes the life threatening coagulation problems in the perinatal period caused by anticonvulsants, especially phenobarbital and dilantin, used by the mother. He did not describe the possibility of a late form of haemorrhagic disease in exclusively breastfed infants. In those years in Holland 70% of the babies were delivered at home'and exclusively breastfed. No vitamin K was given after birth; this was never routine in Holland. The large series of 425 inf'llnts with the late form ofthe haemorrhagic disease of the newborn reported from Japan was seen during a three year period (1978-1980fl. Of these 425 infants, in 91 cases the vitamin K deficiency could have been secondary to specific disorders such as congenital bile duct atresia, chronic diarrhoea or alpha-I antitrypsine deficiency. In 334 infants vitamin K deficiency was idiopathic, of which 286 were exclusively breastfed and 48 partially. Intracranial haemorrhage was present in 87%. In the late form more intracranial haemorrhage was seen contrary to the classic form which has more gastrointestinal bleeding, well-known as melaena neonatorum. McNinch reported six cases from 7000 deliveries during a 17-month period in Devon (1: 1200) in 19844• He speaks of a resurgence ofHDN and blames other infant feeding policy such as the increase in breastfeeding and the advice to mothers to avoid cow's milk formula. Sutor reported similar cases", Vitamin K deficiency in the newborn secondary to the use of medicaments is described for anticonvulsants, n-methylthiotetrazole-cefalosporins, rifampicin, isoniazid, salycylates, ethyl morfins, alcohol and coumarin. Because of cases of severe late HDN in Holland, Widdershoven studied prospectivily the idiopathic or primary late HDN in a group of breastfed babies versus a group of bottlefed infants in 1985-19866• No vitamin K was given after birth. In cordblood in 6-10% PIVKA (Prothrombin in vitamin K absence) infants were detected. At 30, 60 and 90 days after birth, ±10% of infants demonstrated PIVKA in the breastfed group, with different infants detected at each test. No PIVKAs were detected in the bottlefed group in the first months oflife. None of the breastfed infants had clinical signs of a bleeding diathesis, the PIVKA levels were much lower than is usual in severe coagulation disorders. However, ten years earlier Van Doorm was not able to show any PIVKA in 43 cordblood samples in Holland". Motohara reports 10 cases of severe idiopathic vitamin K deficiency in breastfed infants aged 27-47 days'', The hypothesis that a low vitamin K level in breastmilk was the cause could not be confirmed. The vitamin K level was low in only three breastmilk samples, in the seven others it was normal and even high in milk for a baby with a severe intracranial haemorrhage. Other attempts to blame a dietary deficiency due to an inadequate intake of vitamin K by the mothers, have proved inconclusive", Late HDN is also seen in England after the administration of vitamin K after birth!", In conclusion, late haemorrhagic disease of the newborn is probably a new disease entity, seen in the 1980s in exclusively breastfed babies and is characterized by intracranial haemorrhage. Breastmilk in industrialized countries is contaminated with polychlorobiphenyls(PCBs), polychlorinated dibenzo-p-dioxins (PCDDs) and polychlorinated dibenzofurans (PCDFs). In 1966 Jensen in Sweden reported a new chemical hazard in breastmilk, the well-known PCBSll. Dioxins and furans in breastmilk were first reported by Rappe in 1984 in milk of mothers living in north Sweden and western Germany, areas not thought of as contaminated with dioxinst'', Because of the striking similarities in toxicity and environmental fate, and the fact that all three (PCBs, PCDDs and PCDFs) are present in breastmilk in industrialized countries the three chemicals are usually discussed together. PCBs were produced in large quantities in chemical factories because of their properties of insulation and low-inflammability and they were used in transformators and capacitors (closedsystems) and in carbonless copypaper and wood preservative (open systems). In Holland, PCBs were never manufactured but the pollution of the Dutch environment with PCBs is among the highest in the world due to the level of chemicals present in the rivers Rhine and Meuse. In Leiden, breastmilk of 23 mothers was analysed for PCB S13. A mean of 1.48 mg/kg fat PCBs was Presented in Amsterdam at joint meeting of Section of Paediatrics and Academisch Ziekenhuis, University of Amsterdam, 28 May 1988