A Primer on the Vitamin K Injection at Birth

vitamin kMy first thought in everything is how does it relate to the way our bodies are designed? If something sounds too fantastic, it’s probably false. If someone tries to tell me that I need some magic pill in higher quantities than I would normally get from a healthy diet, even if it’s a naturally-occurring substance, I question that.

There are obviously cases where microevolution has resulted in the development of certain traits which have some protective effect but nonetheless have unfortunate consequences. For example, sickle cell anemia is widely regarded to be an evolutionary adaptation to cope with malaria because it has an obvious protective effect against malarial diseases and arose in areas of the world where malaria is endemic and is virtually unknown in ethnic groups that did not originate from malarial areas. Nevertheless, it goes without saying that sickle cell anemia comes with certain deleterious effects.

However, if all of humanity, regardless of race or ethnicity or region of origin, have the same trait, I don’t think we can call it a microevolutionary adaptation or assume that its potential deleterious effects outweigh its known or unknown benefit. And if someone tries to tell me that a certain characteristic shared by the whole of humanity needs to be corrected, I pause and think quite a bit about it. For example, as a midwife, I think it goes without saying that the idea that all first time moms need an episiotomy is ludicrous. In my opinion, another great example is vitamin K. My goal with this article is to give you another perspective to consider in your research, not to change your mind or offer medical advice.

Vitamin K is necessary for blood clotting and vitamin K deficiency is a risk factor for uncontrolled or excessive bleeding. Because only a very small amount of vitamin K is necessary for blood clotting, such a deficiency is extremely rare in adults and is usually associated with severe malnutrition, intestinal disorders, malabsorption, or renal failure. However, in neonates, vitamin K levels are much lower than in adults due to both exogenous and endogenous “deficiency”—i.e., insufficient colonization by intestinal bacteria which produce vitamin K2 (endogenous) or the “low” vitamin K1 and K2 levels in breastmilk and “low” transfer across the placenta (exogenous) (Lippi & Franchini, 2011, pp. 5-6, 8). In fact, vitamin K is traditionally said to be undetectable in cord blood (Greer, 2001), but studies have found vitamin K present in cord blood when pregnant mothers were supplemented orally (by mouth) or parenterally (by injection) (Anai et al, 1993; Shearer et al, 1982). Vitamin K is lower in concentration in the breastmilk than researchers consider necessary for newborn dietary intake (Lippi & Franchini, 2011, p. 6); however, the vitamin K levels in human breastmilk are labeled “low” because they are low in comparison to cow’s milk, but there is no evidence that the levels in human milk are lower than they should be or that cow’s milk is better for human newborns than is human milk (Wickham, 2001). Furthermore, the physiology of hemostasis (blood clotting or stopping the flow of blood by other means) in childhood is quite different from that in adults, so the “vitamin K deficiency” of the newborn period doesn’t affect newborns the same way it would affect adults (Lippi & Franchini, 2011, pp. 6). In fact, the hemostatic system matures between 3 and 6 months of age and two vitamin K researchers commented, “It is, therefore, essential to acknowledge that the differences observed between adults and infants are probably physiological and do not always reflect an underlying pathological condition. Several clinical observations support the hypothesis that children have natural protective mechanisms that justify the existence of these broad variations, since they have both an increased capacity to inhibit thrombin and a decreased capacity to generate it.” (Lippi & Franchini, 2011, p. 8).

Hemorrhagic disease of the newborn (HDN) is said to be caused by vitamin K—i.e., vitamin K deficiency-related bleeding (VKDB)—if administration of vitamin K stops the bleeding, though obviously vitamin K may help even in cases where the bleeding is not due to true vitamin K deficiency, so estimations of the number or proportion of babies with HDN that is due to vitamin K deficiency are probably all fallacious (i.e., an unknown number of babies with VKDB are actually not directly due to vitamin K deficiency). So-called VKDB in the newborn may be due to drugs given to mom or baby such as Coumadin, a hereditary hepatobiliary/malabsorption disease such as cystic fibrosis or biliary atresia, or autosomal recessive vitamin K-dependent coagulation factor deficiencies (though in these cases, non-vitamin K-dependent coagulation factors are also deficient, so it’s obviously an issue of deficient coagulation factors in general, not of deficient vitamin K). If VKDB is idiopathic (meaning we don’t know the cause), researchers blame breastfeeding because of the “low” levels of vitamin K in breastmilk (Lippi & Franchini, 2011, pp. 6-7; Wickham, 2001).

It has been suggested that the relatively low level of vitamin K in neonates as compared to adults is intentional, providing a protective effect against clotting disorders (Wickham, 2001). In fact, one study found a 26% incidence (17/65) of asymptomatic intracranial hemorrhages (harmless brain bleeds) in full-term neonates undergoing uncomplicated deliveries following labors of normal length and that these hemorrhages were not associated with differences in gestational age at delivery, Apgar score, duration of hospital stay, birth weight, or head circumference compared to 0% (0/23) of those delivered by caesarean (Looney et al, 2007). After excluding those who had positive evidence of an intracranial hemorrhage on the first MRI and negative evidence on a second MRI (in other words, they excluded all false-positives as well as all infants whose intracranial hemorrhages cleared up in the interim), another study (Rooks et al, 2008) found 51% (32/63) of all newborns delivered vaginally had intracranial hemorrhage. The rate of intracranial hemorrhage in vaginally-delivered infants excluding those delivered with the aid of vacuum or forceps was 47% (22/47) as compared to 60% (6/10) of newborns delivered with vacuum and 67% (4/6) of infants delivered with forceps, compared to 18% (4/22) of babies delivered by caesarean (Rooks et al, 2008). If we add up the numbers between these two studies for uncomplicated vaginal deliveries without use of vacuum or forceps, the asymptomatic intracranial hemorrhage rate is 35% (39/112). (For those delivered by caesarean between the two studies, the proportion with intracranial hemorrhage is 7% [4/55].) Furthermore, retinal (eye) hemorrhages are found in 20-40% of newborns and red blood cells are not uncommonly found in the cerebrospinal fluid of newborns (Looney et al, 2007). If bleeding—probably due to the normal trauma of uncomplicated vaginal deliveries, considering that the intracranial hemorrhage rate is significantly lower in babies delivered by caesarean—is so common in newborns, with intracranial hemorrhage occurring in up to half and retinal hemorrhage occurring in about one third of the asymptomatic population, perhaps this indicates a strong protective effect of the low vitamin K. Perhaps the purpose is to prevent damage caused by blood clots in the brain and eyes and even the spinal cord. Or, as I would like to put it, maybe God didn’t make a mistake after all!

So when we say all moms or babies or people across the entire planet need more of a certain substance—even a natural substance like vitamin K or vitamin C—for health in general, I take very serious pause because it implies that God (or nature) made a mistake in the design of the human body, and that just doesn’t make sense. The more we learn about the human body, the more we discover that there truly are purposes for the “problems” or “deficiencies” we previously considered entirely problematic. There are obviously times when vitamins may be used medicinally (as in the case of vitamin K for babies with HDN or vitamin C for various conditions), but to say that all humans require far more on a regular basis than we would get from a good diet and that we all therefore must supplement orally or parenterally is, in my opinion, fallacious.

In the end, every parent must weigh the pros and cons and make their own informed decision on the matter.

 

REFERENCES

Anai, T., Hirota, Y., Yoshimatsu, J., Oga, M., & Miyakawa, I. (1993). “Can prenatal vitamin K1 (phylloquinone) supplementation replace prophylaxis at birth?” Obstetrics and Gynecology, 81(2):251-254. Retrieved from <http://journals.lww.com/greenjournal/Abstract/1993/02000/Can_Prenatal_Vitamin_K1__Phylloquinone_.21.aspx&gt;.

Lippi, G., & Franchini, M. (2011). “Vitamin K in neonates: Facts and myths.” Blood Transfusion, 9(1):4-9. PMCID: PMC3021393. doi: 10.2450/2010.0034-10. Retrieved from <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3021393/&gt;.

Looney, C.B., Smith, J.K., Merck, L.H., Wolfe, H.M., Chescheir, N.C., Hamer, R.M., & Gilmore, J.H. (2007). “Intracranial hemorrhage in asymptomatic neonates: Prevalence on MR images and relationship to obstetric and neonatal risk factors.” Radiology, 242(2). doi: http://dx.doi.org/10.1148/radiol.2422060133. Retrieved from <http://pubs.rsna.org/doi/full/10.1148/radiol.2422060133&gt;.

Rooks, V.J., Eaton, J.P., Ruess, L., Peternabb, G.W., Keck-Wherley, J., & Pedersen, R.C. (2008). “Prevalence and evolution of intracranial hemorrhage in asymptomatic term infants.” American Journal of Neuroradiology, 29:1082-1089. doi: 10.3174/ajnr.A1004. Retrieved from <http://www.ajnr.org/content/29/6/1082.full&gt;.

Shearer, M.J., Rahim, S., Barkhan, P., & Stimmler, L. (1982). “Plasma vitamin K1 in mothers and their newborn babies.” Lancet, 2(8296):460-463. PMID: 6125638. Retrieved from <http://www.ncbi.nlm.nih.gov/pubmed/6125638&gt;.

Wickham, S. (2001). “Vitamin K – An alternative perspective.” Association for Improvements in the Maternity Services Journal, 13(2). Retrieved from <http://www.aims.org.uk/Journal/Vol13No2/vitk.htm&gt;. Originally from Wickham, S. (2000). “Vitamin K – A flaw in the blueprint?” Midwifery Today, 56:39-41.

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