Vitamin K Deficient Bleeding (Hemorrhagic disease of the newborn)

Newborn infants need intramuscular injections of Vitamin K in order to produce critical clotting factors. If they don’t get it they can have potentially life threatening bleeding.


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  • American Academy of Pediatrics, Committee on Fetus and Newborn.  Controversies Concerning Vitamin K and the Newborn.  Pediatrics 2003 July; 112(1):191-2.
  • Ross, JA, Davies SM. Vitamin K prophylaxis and childhood cancer. Med Pediatr Oncol. 2000 Jun;34(6):434-7.
  • Cornelissen, M., et al.  Prevention of vitamin K deficiency bleeding: efficacy of different multiple oral dose schedules of vitamin K.  Eur J Pediatr.  1997 Feb; 156(2):126-30.
  • Greer, FR, et al. Improving the vitamin K status of breastfeeding infants with maternal vitamin K supplements. Pediatr. 1997 Jan;99(1).
  • Kher P, Verma RP. Hemorrhagic Disease of Newborn. [Updated 2023 Jun 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from:


Note: This transcript was partially completed with the use of the Descript AI

Welcome to PEM Currents, the pediatric emergency medicine podcast. As always, I’m your host, Brad Sobolewski. Today, we’re gonna talk about vitamin k deficient bleeding, also known as hemorrhagic disease of the newborn. This is a bleeding disorder that manifests in the first few days to weeks of life after delivery. Under the umbrella are a whole range of hemorrhagic diseases, but the most important is vitamin k deficient bleeding.

I’ll get into why in a moment. Vitamin k itself is a fat soluble vitamin mainly synthesized by gut bacteria. Newborns have minimal vitamin k reserves in a sterile gut. And there’s insufficient placental transfer and breast milk is deficient in vitamin K, so that’s why infants need vitamin K at birth. Without it, they can’t produce clotting factors 2, 7, 9, and 10.

You need all those. In brand newborns, the levels are about 20 percent or less of adult values, but within a month after birth, they arise to within normal limits. Other causes of hemorrhagic disease of the newborn include hereditary clotting factor deficiencies such as hemophilia A or B. And the most common item on the differential, especially for late onset, which we’ll talk about in a moment, is trauma, non accidental or accidental trauma. So why am I covering this topic?

Well, a lot of people out there are actually refusing vitamin k for their newborns. Why? Well, families state that they have concerns about the preservative in the injection, maybe that it could cause autism. It doesn’t. The pain from the injection could be harmful to the infant.

They perceive that the intramuscular vitamin k is a vaccine. It’s not. The dose of intramuscular vitamin K is too high. It isn’t. A potential for adverse reactions to an injection like anaphylaxis.

Anaphylaxis can happen after IV infusion and it’s been rarely reported after I’m injection, like winning the Powerball odds. The injection is perhaps a potential entry for germs, that the intramuscular vitamin K causes cancer. So there was 1 study published in the British Medical Journal in 1990. It raised that concern, suggesting that the risk of cancer was doubled in babies that receive vitamin K after birth. Many studies since then in Europe and the United States have refuted this claim and there is absolutely no association between vitamin k and cancer.

Other concerns about vitamin K include that vitamin K may overwhelm the newborn’s immune system. There’s just a general desire to be natural and perhaps a belief that oral vitamin k prenatally to the mother is more effective, but it isn’t. Furthermore, parents who refuse IM vitamin k tend to refuse other preventative measures, including the Hep B vaccine at birth, prophylaxis against gonococcal ophthalmia, which is really bad, and subsequent routine vaccination. Approximately 1 half of the severe cases of vitamin k deficient bleeding are associated with parental refusal vitamin k during the birth and hospitalization. So hemorrhagic disease of the newborn vitamin k deficient bleeding can be categorized into 3 groups based on the age of onset.

Early occurs within the first 24 hours after birth and it’s generally due to maternal medicines that block vitamin k action. Uh, most commonly, these are anti epileptics like phenytoin, phenobarbital, carbamazepine or primidone. They could also be anticoagulants, coumadin, aspirin or even some antibiotics like cephalosporins. The incidence in infants who have not received vitamin k prophylaxis in parents that are on these medicines could be 6 to 12 percent. Classical vitamin k deficient bleeding happens within 1 week of neonatal life, the second through the seventh day.

With vitamin k, the risk is 0.01 percent. If babies are exclusively breastfed and they don’t get vitamin k at birth, that increases the risks. Late onset is from 8 days up to 6 to 12 months. And this is generally exclusively breastfed babies and babies with diarrhea, cholestasis or malabsorption because vitamin k absorption is dependent on bile. The risk is about 1 in 15000 to 1 in 20000 births.

Most common symptom of late onset is intracranial bleeding with a mortality of 20 to 50 percent and all the associated morbidity of an intracranial hemorrhage. The reason for the increased risk in exclusively breastfed infants, I. E. Even those who don’t get any solids or anything else, is because there’s only marginal levels of vitamin K in breast milk. Other causes of late onset, cystic fibrosis, celiac, chronic diarrhea, alpha 1 antitrypsin deficiency, and forms of hepatitis.

So if you suspect vitamin k deficient bleeding, take a good history. These are some of the points in the history that could lead to you making the diagnosis. So take a history of the drugs that mom was on during pregnancy, especially anticonvulsants. Preterm babies are at a higher risk. Breastfed or bottle fed?

Again, bottle- or formula fed infants are at a lower risk because fortified feedings have higher levels of vitamin K. Where was the delivery? Home delivered infants don’t have access to immediate vitamin k prophylaxis at the same rates that hospitalized infants do. So physical findings that you might see in a patient with vitamin K deficient bleeding include cephalohematoma, intracranial bleeding, intrathoracic bleeding, like hemoptysis or associated respiratory distress, intra abdominal bleeding, so you can see melena, hematemesis, you know, isolated GI bleed. You know, you could also think intussusception and mccals.

Skin, you’ll see petechiae on the mucous membranes. You’ll see hemorrhage or petechiae inside the mouth, on the gums, in the nose, excessive bleeding after circumcision, bleeding from the umbilical cord stump after it’s cut and if the umbilical cord falls off, bleeding from vaccine sites. And I mentioned it before and I’ll say it again, but intracranial bleeding is the worst possible outcome. It’s associated with late onset vitamin k deficient bleeding, and it presents with a floppy baby, lethargy, feeding difficulties, bulging fontanels, poor respiratory effort, altered consciousness, convulsions or pallor. These are sick looking babies.

So in evaluation, you wanna get a CBC. Uh, vitamin k deficient bleeding will have normal platelet levels. Thrombocytopenia actually suggests a maternal immune thrombocytopenia in a newborn. They can make antibodies to platelets which can cross the placenta. Clotting profile, the INR will be greater than 4, because again those factors are needed for proper blood clotting.

The PT will be more than 4 times normal. That’s increased due to decreased activity of factor 7. The PTT will also be increased due to decreased activity of factors 2, 9, and 10. The clotting time will be increased due to clotting factor deficiencies, but fibrinogen levels will remain normal. Protein induced by vitamin k antagonists, PIVCA, I guess.

There’s an estimation you can get a lab on that. Any amount of PIVCA is abnormal and indicates vitamin k deficiency. This disappears around day 5 after the administration of vitamin k, but this lab is not part of the routine ED evaluation. Imaging is targeted at the differential diagnosis in the site of bleeding. So get a chest x-ray or an ultrasound, determine if there’s bleeding in the body cavities, you know, the chest or the abdomen.

Um, CT and MRI are most useful to evaluate for intracranial hemorrhage. So treatment. Uh, vitamin k at birth. I think I mentioned that before. So for an infant that’s greater than 1500 grams, so most of the babies that you’ll be taking care of, 1 milligram I’m Less than 1500 grams, 0.3 mgs per kg up to 0.5 mg per kilogram I’m Intravenous vitamin K is not recommended for prophylaxis in preterm infants.

The form that we now give is vitamin K1, It’s a naturally occurring fat soluble form of vitamin k. So before the introduction of vitamin k 1, long before any of us trained, they used vitamin k 3. K3 was a synthetic water soluble derivative. And in higher doses, it was associated with kernicterus hemolytic anemia and hyperbiliruminemia. So vitamin K1, current version, very safe.

Again, in the US, intramuscular vitamin K at birth is recommended. There are no known toxicity or side effects associated with vitamin K1. Now in some parts of Europe, they’ll do oral regimens at birth, at 2 to 4 weeks, and at 6 to 8 weeks. Uh, they can be weekly or even daily. There’s no licensed oral form for newborns in the US.

Some have given infants the injectable liquid by mouth, but it’s not observed and that’s an unstudied intervention. There’s no safety or efficacy data available on that route of administration. In countries that have gone to oral prophylaxis, failures, even with good compliance, have been reported. Failures have not been reported with routine I’m prophylaxis. So based on the available observational evidence, a single I’m dose of vitamin k appears to be more effective in preventing late onset vitamin k deficient bleeding versus oral regimens.

So maternal dietary changes have little effect overall on vitamin K status of the newborn. There was 1 smaller study that showed that 5 milligrams a day or 800 percent of the recommended daily allowance may raise infant serum levels to near formula fed infants in moms that are breastfeeding. But there’s no FDA approved multivitamin that contains that amount of vitamin K. So if you have a baby with hemorrhagic disease of the newborn, in early and classic forms, the treatment is oral vitamin K, 2 milligrams dose, repeated at 2 to 4 weeks and 6 to 8 weeks. And so again, these are milder forms of bleeding.

All breastfed babies with diarrhea and malabsorption situations require an additional postnatal dose of vitamin K to prevent late onset vitamin K deficient bleeding. For the late form of the disease, oral vitamin K is not as efficacious as parenteral. Hence, the 0.5 to 1 milligram single I’m dose should be administered. A presumptive diagnosis of vitamin k deficient bleeding should be made in an infant presenting with bleeding or neurologic symptoms, and either a prolonged PT and or INR, a history of not receiving vitamin k prophylaxis at birth. You should immediately give them 1 to 2 milligrams IV or sub q.

The vitamin k dose should normalize the coagulation profile within 2 to 3 hours. Infants may need resuscitation with blood products if they’ve lost more than 20 percent of their blood volume. And remember, a newborn can become hypotensive by bleeding enough inside their brain. And also, babies may need 10 to 20 ml per kilo of fresh frozen plasma. I’m going to leave you with a quote from Stanford University and Lucille Packard Children’s Hospital.

So the success of vitamin K prophylaxis has been so dramatic that many practitioners have actually never seen an infant afflicted with hemorrhagic disease of the newborn or vitamin k deficient bleeding. Now, it’s a popular trend in some areas to refuse prophylaxis in an effort to keep things natural for the infant. However, it’s important to keep in mind that the infants most at risk for the classic form of the disease are healthy babies who are exclusively breastfed. So we need to work closely with the parents who refuse vitamin k to help them understand the need for prophylaxis and the severity of the disease. The benefit of using I’m vitamin k injection should be explained to parents.

For those that refuse injection, counseling about the adverse effects of vitamin k deficient bleeding should be explained. The alternate oral dose of 2 milligrams should be recommended in the parents that strictly refuse I’m along with a repetition of that dose at 2 to 4 and then 6 to 8 weeks of age. Alright. So that’s all that I’ve got for this episode on vitamin k deficient bleeding AKA hemorrhagic disease of the newborn. Hopefully, you will feel armed to discuss vitamin k refusal with parents, as well as understand the different forms of the disease, including early, which is related to maternal medicines, classical, which is exclusively breastfed infants who don’t get vitamin k at birth, and the late form, which is the most dire and presents often with intracranial hemorrhage. If you have ideas for other episodes or topics you’d like to suggest, send them my way. I will take your feedback via email, a comment on PEMBLOG, a direct message on a social media platform, a snail mail.

However you wanna get feedback in my direction, let me know. Encourage your colleagues to listen to the podcast as well. More listeners means more learning. And, hey, I know that this can be a tough tough topic to discuss with some parents. I think we’re all better armed to have those conversations if we practice them beforehand.

So hopefully, this episode will prepare you for the next time you meet a newborn whose parents are using vitamin k. For PEM currents, the pediatric emergency medicine podcast, this has been Brad Sobolewski. See you next time.


Agitation in Neurodivergent Children

“Neurodivergent” is a term used to describe brain functionality and how it differs in some people. These individuals perceive, interpret and interact with the world in ways that are different than what we typically encounter. The Emergency Department is a potentially challenging and stressful place for Neurodivergent children, and this episode discusses strategies to help make their experience just a little bit better.

This episode features the talents of Ilene Claudius, MD, the Director of Quality and Process Improvement for the Emergency Department at and Alice Kuo, MD, Professor and Chief of Medicine-Pediatrics and Preventive Medicine – both at UCLA.

It is also a co-production of the Emergency Medical Services for Children Innovation and Improvement Center whose mission is to minimize morbidity and mortality of acutely ill and injured children across the EMS for children continuum.

To learn more about the Emergency Medical Services for Children Innovation and Improvement Center visit


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EMSC IIC Pediatric Education and Advocacy Kit (PEAK): Agitation

De-escalation tips for pediatric agitation: EMSC Innovation & Improvement Center


The Emergency Medical Services for Children Innovation and Improvement Center is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (U07MC37471) totaling $3 million with zero percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit



Yes, PEM Currents is a Pediatric Emergency Medicine podcast, but during the COVID-19 pandemic we may be tasked with seeing patients outside of our area of expertise. Plus, there’s a lot we can learn from big people that we can extrapolate to children. I have partnered with POPCoRN, the Pediatric Overflow Planning Contingency Response Network to deliver content that will benefit those of us who may have been asked to care for adults both in their native habitat, and in our pediatric facilities. This episode, brought to you by yours truly and Barrett Burger, a Medicine-Pediatrics Resident from the University of Arkansas focuses on delirium and confusional states and delivers some sound advice on how to address the confused patient. Though this is geared towards the care of adults there are some great pearls to help with patients of any age.

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Things We Do for No Reason: Neuroimaging for Hospitalized Patients with Delirium. J. Hosp. Med. 2019 July;14(7):441-444. March 20, 2019. | DOI 10.12788/jhm.3167

Inouye SK. The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med 1994; 97:278.

Inouye S, Westendorp R, Saczynski J. Delirium in elderly people. Lancet. 2014;383(9920):911-922.

Marcantonio. Delirium in Hospitalized Older Adults, NEJM, 2017.

Setters B, Solberg LM. Delirium. Prim Care 2017; 44:541.

Shenvi. Assessing and Managing Delirium and Older Adults. Academic Life in Emergency Medicine. July 25, 2015. Accessed June 7, 2020.



Factor First!

OK, did I get your attention? Hopefully I did, because giving replacement factor to children with hemophilia presenting to the Emergency Department as soon as possible is the most important thing that you can do to positively impact outcomes. This episode of PEM Currents focuses on the different bleeding complications seen in Hemophilia and Von Willebrands and reviews basic management. There is a companion post on that has more detailed information that you should check out as well.

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Di Michele D, Neufeld EJ. Hemophilia: a new approach to an old disease. Hematol Oncol Clin North Am. 1998;12(6):1315- 1344.

Di Michele D. Inhibitor treatment in haemophilias A and B: inhibitor diagnosis. Haemophilia. 2006;12(Suppl 6):37-42.

Labarque V, Stain AM, Blanchette V, et al. Intracranial haem- orrhage in von Willebrand disease: a report on six cases. Heamophilia. 2013;19(4):602-606.

Melchiorre D, Linari S, Innocenti M, et al. Ultrasound detects joint damage and bleeding in haemophilic arthropathy: a proposal of a score. Haemophilia. 2011;17(1):112-117.

Nagel K, Pai MK, Paes BA, et al. Diagnosis and treatment of intracranial hemorrhage in children with hemophilia. Blood Coagul Fibrinolysis. 2013;24(1):23-27. 

Oren H, Yaprak I, Irken G. Factor VIII inhibitors in patients with hemophilia A. Acta Haematologica. 1999;102(1):42-46.

Schwartz et al. Hemophilia And Von Willebrand Disease In Children: Emergency Department Evaluation And Management. EB Medicine, 2015.

Witmer C, Presley R, Kulkarni J, et al. Associations between intracranial haemorrhage and prescribed prophylaxis in a large cohort of haemophilia patients in the United States. Br J Haematol. 2010;152(2):211-216. 

Witmer CM, Raffini LJ, Manno CS. Utility of computed tomography of the head following head trauma in boys wth haemophilia. Haemophilia. 2007;13(5):560-566. 



I never thought that this particular disease would make a comeback in the United States. But here we are. Measles. As of May 2019 there have been cases reported in over 20 states. Declining vaccine rates and international travel to areas with local measles epidemics have led to a sharp rise in the number of cases in the US. The goal of this epode of PEM Currents is to discuss the diagnosis, treatment and prevention of measles, as well as how you can recognize it and appropriately diagnose and report cases.

You should definitely check out the following resources – since measles is a visual illness with a memorable rash (not that most of us have actually seen it). as well as learn about local hospital and health department procedures for treating, isolating and reporting confirmed and suspected cases.

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CDC – Measles (Rubeola) – Main Page

CDC – Photos of People With Measles

CDC – Measles Cases and Outbreaks

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With summer pool season in full swing allow me to freestyle a little on a common topic that many Emergency Departments and Urgent Cares seem to be swimming in every summer. This episode of PEM Currents dives right into Otitis  Externa – AKA Swimmer’s Ear and reviews diagnosis and treatment. If you were treading water and looking for this topic the wade is over.



Beers SL, Abramo TJ. Otitis externa review. Pediatr Emerg Care. 2004;20(4):250.

Osguthorpe JD, Nielsen DR. Otitis externa: Review and clinical update.. Am Fam Physician. 2006;74(9):1510.

Roland PS, Younis R, Wall GM. A comparison of ciprofloxacin/dexamethasone with neomycin/polymyxin/hydrocortisone for otitis externa pain. Adv Ther. 2007;24(3):671.

Rosenfeld RM, Singer M, Wasserman JM, Stinnett SS. Systematic review of topical antimicrobial therapy for acute otitis externa. Otolaryngol Head Neck Surg. 2006;134(4 Suppl):S24. 

Russell JD, Donnelly M, McShane DP, Alun-Jones T, Walsh M. What causes acute otitis externa?J Laryngol Otol. 1993;107(10):898.


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Take a deep breath and PEEP this – PEM Currents, the Pediatric Emergency Medicine podcast proudly brings you an episode dedicated to the initial assessment and management of respiratory distress. Whether you’ve been practicing in the field for 20 years or are fresh out of medical school it is important to recognize key symptoms in children with difficultly breathing, and to avoid delaying essential supportive care.


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This episode focuses on upper GI bleeds. Serious UGI bleeds – you know, the ones with shock, massive transfusions and more – are fortunately rare in the Pediatric Emergency Department. However, there is a growing population of patients with chronic diseases that can lead to portal hypertension, varies and other causes of bleeding from the upper GI tract.



With the recent influenza epidemic you may have also seen a rise in the number of cases of parotitis. This should not be a surprise, as acute parotitis is usually viral, self-limited and treated with supportive measures – just like the flu! Learn more by listening to this edition of PEM Currents, which is all about acute parotitis.


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PEM Currents returns with a look at topical anesthetics used in the Emergency Department. Specifically this edition of the podcast will focus on LET, EMLA and LMX and discuss typical use.