This blog post is the transcipt from a recent podcast episode of the same name (from The Doula's Guide To Preparing For Your Birth - season 2, episode 7)
Vitamin K it is a big topic and one that I am constantly asked about, when planing for the podcast I wanted to ensure I could do it justice and include lots of information and also raise some questions around this routine part of maternity care, but sensitively and without bias. I have had clients choosing all sorts of options with regards to vitamin K, some choosing to have the injection without question and some choosing to have it after asking all the questions, others choosing to decline without question and others doing huge amounts of research and then deciding to decline - and all of those clients made the right decisions because they did what was right for them, hopefully this podcast episode and blog will help you decide what is right for you, or at least give you the info to go away and work is out! Strap yourself in, it’s going to be a long one.
What is vitamin K, so the vitamin K which we’re talking about is a man-made vitamin named Phytomenadione, it’s not the same as natural vitamin K which we get from food sources like green leafy vegetables or real butter. Natural vitamin K is actually a group of vitamins which help our blood to clot and our wounds to heal and I think this is the first place that people stumble in that they don’t realise what we are giving to our newborns is a man made version and it is classed as a medicine, something we are rarely ever told. But essentially it does the same thing, the medicine works by helping the body make blood clotting factors. These blood clotting factors help stop bleeding. So the patient information leaflet states that “giving phytomenadione prevents and treats bleeding caused by a lack of vitamin K. This is called ‘vitamin K deficiency bleeding’ (VKDB). which is a serious, but rare condition. All newborn babies are given vitamin K1 with their parent’s permission.” We’ll talk about VKDB in a moment. The vitamin can be given by injection to your newborn within the first few hours of their life so this can happen wherever you’ve given birth, it’s not something you need to go to the hospital for, if you’re choosing to birth elsewhere the midwives have it on hand and they’re not gonna disturb your golden hour to give your baby this injection but they like to get it done within that couple of hours after birth when they’re doing newborn checks and then they can leave you to it, go home or discharge you or whatever the plan is. This injection goes into babies thigh, if you’re breastfeeding then they will encourage you to feed baby so you’re comforting them because obviously injections hurt or the other option is to give them this medication by oral drops so the liquid substance just popped into their mouth again at the same time so a couple of hours after birth, with this option you then have to top it up, so where I am you get a second dose when baby is 7 days old and a third dose at day 28, this is a little different in some areas but mostly follow this or a similar pattern. The reason for these follow up drops is because the vitamin K is not absorbed as well when given orally as via the injection so they require a top up to keep the levels up.
Why are they giving it in the first place? Because babies are born with low levels of vitamin K and noone really knows why for sure (which poses questions of it’s own we will talk about in a little bit), but we can surmise that these things contribute - it doesn’t cross the placenta very well, then breastmilk contains low levels too so it’s not being topped up after birth if you are exclusively breastfeeding, and please please please don’t let this put you off exclusively breastfeeding because there are a whole wealth of other benefits come into play here and it is absolutely not a ‘fault’ with breastfeeding, it’s just not one of the main components of breastfeeding which is neither here nor there, poor vitamin K content in breast milk does not appear to cause VKDB either and this is backed up by scientific studies. Babies also have immature gut flora which doesn’t lend well to absorbing the vitamin K which does come in from the breastmilk and is then poorly absorbed in the intestines. So a multitude of factors come into play here. But the question I mentioned this raises for some is - is it intentional that babies have low levels of vitamin K? Babies who are born at term with no medical conditions who are otherwise healthy - their levels of everything else are perfectly fine, so maybe their levels of vitamin K are fine too and they don’t really need us all up in their business trying to rectify something that doesn’t need rectifying? So that’s just something to ponder right now, i’m not advocating for either side here I’m just trying to cover all bases and all viewpoints and that is a pretty prominent viewpoint of a lot of people who decline vitamin K, that there must be a reason it is lower, we’ve evolved to a point where everything is as it should be and again we’ll talk more about that in a little bit.
It’s also worth mentioning that assuming all babies have a vitamin K deficiency is from a time when delayed cord clamping simply wasn’t a thing, so babies were born and their cords were almost instantly clamped and cut and then they had lower levels of vitamin K, it would be interesting to see if the levels differed across the board in babies who had optimal cord clamping or even lotus birth for example so their cords were simply left to go white before being interfered with as a whole, it may be different, still low but maybe not as low. Lots of questions around this, it would be hard to know on such a large scale as even though now in the UK optimal cord clamping is becoming more common it is still not happening as standard, delayed cord clamping IS standanrd but delayed cord clamping is often not long enough for babies cord to go white and for ALL of the blood and nutrients to cross the placenta into baby and that’s what we mean by optimal cord clamping. From what has been studied though vitamin K levels in the cord blood are often below the detection limit of 0.02 ng/mL(Nanograms per milliliter and a nanogram is one-billionth of a gram so teeny tiny amounts) in healthy newborns regardless of their gestational age so ya know, we can surmise that it probably wouldn’t make a whole heep of difference, but optimal cord clamping is still something I will harp on about forever because it is SO important.
But back to the point I was making so we were asking why is vitamin K given routinely and we’ve established babies are born with low levels of vitamin K and so we give this synthetic version to prevent VKDB. VKDB is a rare but life threatening condition which affects babies in 3 ways, so there is early VKDB which is where it presents within 24 hours of babies being born, classic which is within 1 week of being born and is the most common and late which is where it presents from week 2 post birth up to 6 months post birth. With VKDB babies cannot stop bleeding because their blood does not have enough Vitamin K to support forming a clot, the bleeding can occur anywhere on the inside or outside of the body so it may be visible from noses or eyes but it can also happen inside their bodies or in their brains and this is less easy to spot. Signs to look out for are smaller or minor bleeds from the skin, nose or mouth as these babies are more likely to go on to develop bleeding in the brain, likewise bruising from an unknown or small cause. Babies who are still jaundiced after 2 weeks who are also not gaining weight, have pale stools, dark urine or are usually ill, so if you are choosing to decline you may wish to just have these in the back of your mind as something to look out for but again I do want to reiterate that these can be hard to spot and there may also be no prior warning signs to a more serious bleed occurring.
After that heaviness I feel it important to also reiterate how rare this is so please, please, please don’t walk away from this feeling terrified, I know the mental load of being pregnant, especially for any first time mums, can be incredibly worrying and anxiety inducing thinking about all of the things you need to consider for your babe and I do not want to add to that so let this hopefully reassure you. VKDB roughly effects 1 in 11,000 full-term babies if they DO NOT get extra vitamin K (figures vary but this seems to be the median and widely agreed figure), so if you decline the vitamin K dosage at birth your baby has a 0.01% chance of developing VKDB so absolutely tiny but still a risk, in the UK it’s thought that if it wasn’t given then between 10-20 babies out of the 800,000 recorded births in the UK every year could be brain damaged as a result of a bleed in the brain, and four to six babies could die. So with vitamin K given the chance of a baby developing a brain bleed from VKDB in the UK is 0.0018% and the chance of them dying is 0.000625% and I’m really sorry if this is hard to hear, it’s a truly horrible thing to think about but to put that into perspective there are everyday things we do which are much, much riskier and we don’t even think twice about - research suggests that for every 1000 miles you drive your chances of getting into a car accident are 1 in 366 which is 0.27% but none of us are particularly worried about that are we - and I’m not comparing the two or saying we shouldn’t worry about these risks, I’m just saying - there is risk involved in EVERYTHING in life, from getting out of bed, to driving to work etc and comparatively the risks of a baby developing VKDB without accepting vitamin K are teeny tiny and the chance of them developing it when accepting the vitamin K are even teenier and tinier so please don’t let this consume your thoughts or your worries. It is INCREDIBLY rare.
There are also some risk factors which can contribute to babies developing VKDB, those are babies who are premature, babies who have liver disease that may show as prolonged jaundice or as other symptoms such as those mentioned above, those who fail to take or find it hard to absorb feeds or are ill for other reasons, but I can’t find any solid research into how much the risk actually increases when these risk factors are present, they seem to be only slightly significant and the numbers are still SOO small. Maternal malabsorption disorders and medications that inhibit the activity of vitamin K, such as antiepileptics, certain antibiotics (cephalosporins), and vitamin K antagonists (for example blood thinners like warfarin can increase the risk to baby) and recent studies have also suggested that pregnancy conditions such as pre-eclampsia and intrauterine growth restriction in which placental functions would be impaired may affect the placental transfer of vitamin K thus increasing the risk.
So that is VKDB in a nutshell and that is why vitamin K is given, now let's chat about if it is safe. I’ve already mentioned that it is a proven and effective way to reduce the risk of VKDB and to up the levels of vitamin K in your babes and for most people that’s enough, that is all they need to know and if that is you that’s absolutely fine! VKDB is life threatening and the vitamin K injection or drops are a proven way to reduce the risk of this, that is a fact regardeless of whether you agree with accepting it or not, it is a fact that it lowers the risk to almost nothing, it’s super small anyway but it does lower it even further which could (and does) save babies lives.
So the pros of your baby receiving vitamin K - it does it’s job, it lowers the risk of your baby developing VKDB - great. It’s thought to be low risk in terms of side effects too but we’ll cover that in a second. It’s also the only option, questions have been asked around efficiency and policy and if there are alternative options and basically nothing is likely to change because this is a cost effective way for improving short-term outcomes so it’s either accept or decline, there is no in between option. Interestingly there is an alternative that seems to work but is unaccessible to us - there has been a screening test program to detect vitamin K deficiency in a breastfed infant population in Japan using Normotest (which is essentially a blood coagulation test) via heel puncture and blood specimens collected in microtubes, so like when you go for the heel prick test in the UK (im not sure if this is a thing everywhere!). However, the screening test program was substituted for prophylactic vitamin K administration and the reasoning given was ‘because heel punctures are more invasive, difficult, and expensive than vitamin K administration’. so like everything it comes down to money of course, they would rather just give every baby vitamin k than have to test all babies blood and then have to treat some of them, I’m sure there is more to it than this but I just thought this was interesting food for thought, i’m sure a lot of people would prefer a blood test over an injection but it’s simply not something we’re offered, and also blood tests are not risk free either of course but that is a different discussion.
Slightly off topic there so lets steer it back and to summarise - potentially life saving is enough of a pro for people and that’s where we are gonna leave this segment because I’ve already covered all of the research and reasoning around this!
The cons or the reasons why people decline vary massively, I’ll start off by talking about the standardised side effects but as I’ve just said for most people this is actually a plus because the side effects are so few and so what you’re doing is weighing up do the benefits of this lowering the risk of VKDB outweigh the side effects if accepting - so just like you would anything else in pregnancy. Use the BRAIN tool, if you don’t know what I’m talking about then listen to my podcast episode on decision making in pregnancy or better yet sign up to my online course, click here for more info - yes this is a shamless plug.
Let's talk about what the patient information leaflet says about the side effects, which by the way should be given to ALL parents before their baby is given vitamin K but isn’t - it really drives me mad because all medications given by healthcare professionals come with patient information leaflets and they all say at the top “Please read all of this leaflet carefully before your baby or child is given this medicine. Keep this leaflet. You may need to read it again” but in my years as a doula and my own personal experience I have never, nor my clients, been given one of these leaflets, I’m always having to look them up online, but rant aside, I will pop a link to the patient informatin leafleft for vitamin K in the references so check it out if out if you wish. The leaflet states “The following side effects may happen with this medicine: Allergic reactions, the signs may include: Swelling of your baby’s or child’s throat, face, lips and mouth. This may make it difficult for them to breathe or swallow. Sudden swelling of your baby’s or child’s hands, feet and ankles. A reaction where the injection was given, rarely this may be severe. Signs include redness, swelling, pain and it may cause a scar” so those are the only two side effects in the leaflet and for some they may sound monumental and for others they may sound like they're absolutely not worth thinking about ever again. What it doesn’t state however is how often these side effects occur which is quite frustrating because a lot of patient information leaflets are quite forthcoming with this and will say for example 1 in 1000 patients will experience xyz as a side effect but this doesn’t it just says “Like all medicines, Konakion MM Paediatric can cause side effects, although not everyone gets them.” which is quite vague and I’ve tried to research myself but haven’t managed to find any information on how often these side effects occur. In the side effects information of the active ingredients of the drug it states “Rarely, injection site reactions may occur which may be severe, including inflammation, atrophy and necrosis.” so slightly more serious but again it doesn’t say the frequency just "rarely".
Next I want to talk about the ingredients in the synthetic vitamin K, so the main ingredient is Phytomenadione which is the synthetic vitamin K and then you also have Glycocholic acid which is a bile acid and the reason this is included is because babies don’t have a fully developed bile and pancreas system so cannot fully absorb vitamin K, from research I cannot see any side effects to this being included but this is a reason some people state as factoring in to their decision to decline vitamin K - if babies cannot yet absorb vitamin K then should we really be giving them it? Research has shown that absorption is limited in the absence of bile so it must be included but just as we don’t give them anything but breast milk for the first 6 months until they can handle it, should we then be giving them medicines which they cannot yet absorb with acids in that they would have developed themselves naturally in due course? Again I am not advocating for any side, simply stating questions that come up for people when thinking about vitamin K.
Other ingredients are lecithin which is a fatty substance essential to many cells in the body, generally considered safe but side effects of taking it can include diarrhea, nausea
stomach pain, increased saliva in the mouth and a feeling of fullness - whether or not the levels in the vitamin K can cause this I wouldn’t like to say because it’s not listed on the safety leaflet and there is no research I can see into the side effects but those side effects are stated as being caused by consumption of lecithin. Another ingredient is sodium hydroxide, now this is a weird one because this is not something that we as humans should not be digesting and this was a biggie for me when doing my research because sodium hydroxide can be very CORROSIVE and can cause severe burns in all tissues that it comes in contact with however the patient information leaflet does state that “This medicine is essentially ‘sodium free’ as it contains less than 1 millimole sodium per ml (2.64 mg in each millilitre)” so essentially it’s saying it is such a small amount that it is not going to cause harm but it is listed as an ingredient, and it just made me slightly on edge knowing that this compound is used to make drain and oven cleaners, products that explode, dyes, and petroleum products to name a few and yet we’re injecting it in to babies, but I know I know before anyone comes at me as I’ve just stated the levels are so low we shouldn’t be worried it’s just food for thought isn’t it, why do we need this included?
And finally there is hydrochloric acid which is a necessary stomach acid but again when you research this it is also corrosive and it can cause eye damage, even blindness, if splashed in the eyes, can cause severe burns. Ingestion of concentrated hydrochloric acid can cause severe injury to the mouth, throat, oesophagus and stomach, now of course most babies are receiving these vitamin K injections or drops and most babies are not coming away with burns or diarrhoea or going blind are they so I am totally not trying to create hysteria around these medicines which have been 'proven' to be safe, I am simply sharing the ingredients and what they are and what they have the capacity to do because this has been cause for concern for some and for many who chose to decline because they do not want to inject their newborn babies with this stuff when they are brand new and adjusting to life in the world with such fragile immune systems and microbiomes. That’s everything that is included, as I said I will include the patient information leaflet in the references so feel free to go and have a look yourself, also just to mention this is what is given in the UK and I believe in the US too but I’m not sure about anywhere else, it may be a different medication. It's never discussed that there are other ingredients in the vitamin K so even if none of those things bother you and because it’s such small amounts I’m sure it’s not a big deal for a lot of people, but even so I think it’s important to know what we are giving to our babies, especially when they’re fresh out of the womb.
And finally lets talk about why some of the other reasons people chose to decline, so I can’t find the stats on how many people decline vitamin K in the UK but in the US it is estimated that the frequency of refusal of intramuscular vitamin K by parents ranges from 0% to 3.2% in US hospitals, up to 14.5% in home births, and up to 31.0% in birthing centers which is interesting, I don’t think it’s that high in the UK in my experience, I know I have a very small sample size judging on my clients but I feel like more people get it than don’t, especially with my hypnobirthing clients, I think doula clients probably 50/50 but in hypnobirthing clients almost all of them seem to have had it from what I remember and then I always think well I’m in an echo chamber of people who are very well researched and more holistic than your average person giving birth so my numbers are definitely skewed. Also in America the care is very different and it’s paid for so I imagine other factors come in to play. Long winded way of saying I have no idea the stats around uptake verses declining.
A reason I personally hear a lot which has gained a lot of traction is the idea that babies blood is thinner for a reason and that is because the blood which transfers from the placenta in to your baby when they are born is FULL of stem cells, we know this for a fact and that is one of the reasons optimal cord clamping is so important. These stem cells can protect babies against bleeding and also have many many other functions, stem cells are basically the bodies raw material that are able to develop into many different cell types, from muscle cells to brain cells and they self-renew to recreate functional tissues, they’re basically a repair system for whatever our body needs them for and there is this thought which is becoming more prominent in people who are choosing to decline vitamin K that the reason babies blood is thinner at birth is by design - the blood needs to remain thin so that all of these stem cells can easily travel where they are needed and begin to initiate and perform their functions. I realise this may be getting into conspiracy theory territory or whatever now because technically this may not be the actual reason why, but you know it makes sense when you think about it and it is true that the blood is packed full of stem cells and they need to be able to easily transfer through the body, again food for thought, of course babies receiving vitamin K receiving optimal cord clamping also get their full blood quota and full stem cell quota so for many this is more than enough of a benefit and the added peace of mind from the vitamin K negates this worry. Everyone is going to feel differently about this information!
And then following on there was some research done in the US which looked at the reasons given for declining and these were the most popular - concern of harm from the injection, a desire to be natural which then went on to state that additional drivers of the desire to be natural included parents’ religious beliefs and a belief that vitamin K deficiency is to be expected for infants so we spoke about that earlier, how many people believe that the lower levels of vitamin K are normal for babies and we should let their little bodies work as they do in order to rectify the levels themselves in due course. Other reasons include a belief in alternative methods of prophylaxis stating some parents preferred natural sources of vitamin K, and this preference included increasing the mother’s own dietary intake of vitamin K during the pregnancy. Other reasoning given includes concern about preservatives or ingredients, concern about adverse reactions, concern about harmful effect of pain for infant, concern about dose being too high, concern about potentially overwhelming infant’s immune system, desire to minimize their infant’s exposure to “toxins”, and placement of trust and mistrust: so mistrust of the medical and pharmaceutical community and influence from social circles, the Internet, and social media. Which makes sense, it’s very easy to get caught up in other peoples opinions of what is best for you and at the end of the day only you can decide what is best for your baby.
Anddd I’m gonna leave it there because I think I've covered just about everything, it’s something I am constantly asked about and I’ve wanted to talk about this for ages but I wanted to make it respectful to both sides of the argument and try to make it as balanced as possible without spreading any misinformation or causing people to stress and I really hope that has come across, please go away and make decision which feel right for you, not what anyone else is saying or telling you to do, just what is right for you. If you want to accept the injection, that doesn’t make you a neglectful parent, it doesn’t mean you’re not holistic or that you don’t care about your babies health at all, it means you are doing your best to keep your baby safe. And equally if you do not feel that accepting vitamin K is right for you or your baby then again don’t feel like you are a neglectful parent or that you are risking your baby, you are doing the best for your baby. It is for YOU to weigh up the risks and makes the decisions that are right for your family.
Sorry if I’ve boggled anyones minds a little bit with this, and I hope my intentions have come across in the right ways and have hit the right people. Again another note to send my love to anyone who has dealt with VKDB or any other newborn illness, holding space for you in my thoughts.
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Meg x
References:
Vitamin K Deficiency Bleeding in Infancy - click here
Patient Information Leaflet - click here
Vitamin K information leaflet - click here
Refusal of Intramuscular Vitamin K by Parents of Newborns: A Review - click here
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