Haemorrhagic Disease of the Newborn (Vitamin K Deficiency Bleeding)
Haemorrhagic Disease of the Newborn (Vitamin K Deficiency Bleeding)
Vitamin K deficiency bleeding (VKDB), formerly haemorrhagic disease of the newborn, is bleeding caused by inadequate vitamin-K-dependent clotting factors (II, VII, IX and X). It is preventable but may cause fatal intracranial haemorrhage.
Bleeding newborn = emergency: stabilise ABC, obtain urgent glucose and blood samples, give vitamin K by the prescribed route, replace blood components when indicated, and investigate sepsis, DIC, liver disease and trauma.
Types
| Type | Timing | Associations/presentation |
|---|---|---|
| Early | First 24 hours | Maternal medicines interfering with vitamin K; severe internal or intracranial bleeding |
| Classic | Days 2–7 | No/insufficient prophylaxis, delayed feeding; umbilical, skin or gastrointestinal bleeding |
| Late | After first week, commonly 2–12 weeks but may occur later | Exclusive breastfeeding without effective prophylaxis, cholestasis/malabsorption; intracranial bleeding common |
Why Newborns Are at Risk
- Limited placental transfer and low stores of vitamin K at birth.
- Immature intestinal flora and liver.
- Low vitamin K concentration in breast milk, although breastfeeding remains strongly recommended.
- Cholestasis, biliary obstruction, cystic fibrosis, chronic diarrhoea or prolonged antibiotics.
- Maternal anticonvulsants, warfarin or selected antibiotics; failure/refusal of prophylaxis.
Clinical Features
- Oozing from umbilicus, heel-prick, venepuncture, circumcision or injection sites; bruising, petechiae, pallor.
- Haematemesis, melaena, rectal bleeding, haematuria or pulmonary bleeding.
- Intracranial haemorrhage: lethargy, poor feeding, vomiting, bulging fontanelle, high-pitched cry, pallor, seizures, apnoea or unequal pupils.
- Shock: tachycardia, weak pulses, prolonged capillary refill, cool extremities, hypotension and reduced urine output.
Assessment and Differential Diagnosis
- ABCDE, quantify bleeding, check temperature and bedside glucose; establish vascular access without repeated traumatic attempts.
- Ask about prophylaxis, timing/site of bleeding, feeding, jaundice/pale stools/dark urine, maternal medicines, infection and family bleeding disorders.
- Send FBC/platelets, PT/INR, aPTT, fibrinogen, blood group/cross-match, liver tests and cultures if sepsis suspected. Obtain imaging for suspected intracranial or internal bleeding.
- Consider birth trauma, swallowed maternal blood, sepsis with DIC, thrombocytopenia, haemophilia/other factor deficiency, liver failure and vascular lesions.
Emergency Management
- Call neonatal/paediatric help; maintain airway, ventilation, oxygenation, warmth and continuous monitoring.
- Give phytomenadione (vitamin K1) promptly according to neonatal emergency protocol. Do not delay for laboratory confirmation when VKDB is strongly suspected.
- If actively bleeding or shocked, avoid intramuscular injections until haemostasis is improved; use the route prescribed by the senior clinician/protocol.
- Restore circulation with carefully titrated neonatal fluids and compatible packed cells/whole blood; give fresh frozen plasma or other components according to coagulation results and protocol.
- Treat seizures, hypoglycaemia, sepsis or liver disease; seek neurosurgical advice for intracranial bleeding.
- Repeat clinical assessment, haemoglobin and coagulation studies to confirm response.
Nursing Care and Rationales
| Intervention | Rationale |
|---|---|
| Monitor respiration, saturation, heart rate, perfusion, blood pressure, temperature, consciousness, pupils and fontanelle. | Detects shock and intracranial pressure early. |
| Apply gentle direct pressure to external bleeding; count/weigh soaked materials where feasible. | Supports haemostasis and estimates loss. |
| Minimise venepunctures and avoid rectal procedures/IM injections while bleeding. | Prevents additional haemorrhage. |
| Administer vitamin K and blood products exactly as prescribed; perform identity and transfusion checks. | Corrects deficiency and replaces lost blood/clotting factors safely. |
| Maintain strict intake/output and observe urine, stool and vomit. | Assesses perfusion and occult bleeding. |
| Provide seizure precautions and reduced stimulation. | Limits injury and physiological stress. |
| Explain the condition and prophylaxis without blaming parents. | Improves trust and future preventive care. |
Prevention
Every newborn should receive vitamin K prophylaxis soon after birth according to the national protocol. Intramuscular prophylaxis is the most reliable single-dose method. If an oral regimen is used locally, every scheduled dose must be completed because a single oral dose is less reliable, especially with unrecognised cholestasis. Record product, dose, route, site, time and any refusal. Counsel families that prophylaxis does not replace urgent assessment of bleeding or prolonged jaundice.
Complications and Follow-up
- Hypovolaemic shock, severe anaemia and death.
- Intracranial haemorrhage causing seizures, hydrocephalus, cerebral palsy, developmental delay or sensory impairment.
- Recurrent bleeding if underlying cholestasis/malabsorption is missed.
Before discharge confirm bleeding has stopped, coagulation is corrected, feeding and observations are stable, and the underlying cause is addressed. Arrange neurological, developmental, liver or haematology follow-up as needed.
Revision Questions
- Classify VKDB by timing and typical presentation.
- Describe emergency care for a bleeding six-week-old infant.
- Explain seven nursing interventions with rationales.
- How is VKDB prevented?
References
- WHO: Newborns—improving survival and well-being
- WHO recommendations on newborn health
- Uganda Ministry of Health neonatal care and transfusion protocols; current facility formulary.
Drug doses and transfusion volumes must be weight-based and prescribed under the current neonatal protocol.