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Letters to the Editor

Indian Pediatrics 2001; 38: 1198-1199  

Late Hemorrhagic Disease of the Newborn


Deficiency of vitamin K predisposes to early, classic or late hemorrhagic disease of the newborn (HDN); of which late HDN may be associated with serious and life threatening intra-cranial bleeding. A three and half months old male child born to a healthy primiparous mother was admitted with complaints of multiple bluish swellings over body, difficulty in feeding and excessive crying over a period of three days. The baby was a normal full term home delivery with no significant antenatal, perinatal events or past history and was exclusively breastfed till date. There was no history of vitamin K administration at birth.

On examination, the baby weighed 4.3 kg and had tachycardia, moderate pallor and multiple ecchymosis over the trunk and the limbs. He had a bulging and tense anterior fontanel of size 2.5 cm ´ 2.5 cm. He had no mucosal bleed, icterus, hepatosplenomegaly or lymphadenopathy. His CNS examination revealed a shrill cry and a mild hypertonia but no signs of meningeal irritation. His hemoglobin was 7.0 g/dl, with normocytic and normochromic anemia, platelets were 2,40,000/cu mm, prothrombin time was 120 seconds, PTT was 120 seconds and liver function tests were normal. The CSF showed a xanthochromic appearance but no cells or organisms on the microscopy. Due to his deteriorating condition, he could not be taken for CT scan. Studies for the estimation of PIVKA II levels were not available locally. The child received parentral vitamin K and fresh frozen plasma, but died within ten hours of the hospitalization. Based upon the age, clinical presentation and abnormal PT and PTT, a diagnosis of late HDN was logical.

The incidence of late HDN has been reported to be 1 in 14,000 infants when no vitamin K prophylaxis is used at birth. These infants are at a high risk of developing intra-cranial bleeding which has high mortality and high incidence of neurodevelopmental sequelae among the survivors(1). Bor et al. reported a series of 15 infants with idiopathic late HDN over a ten years period and a mortality of 33% in their study(2). Despite the proven effectiveness of intramuscular vitamin K in the prevention of classic HDN and marked reduction in the incidence of late HDN, there have been concerns about the need for and the safety of this prophylaxis(1-3). Selective use of intramuscular vitamin K in high risk newborns is being widely practiced in our country but this would put a small proportion of infants at a definite risk of late HDN who did not receive the prophylaxis at birth(4). In view of high morbidity and mortality of late HDN, and probable under reporting of such cases, there is a need for availability of specific oral formulations of vitamin K and its precise dose and frequency for the prevention of late HDN.

Niranjan Shendurnikar, Hiralal Rana, D.J. Gandhi,

C/21, Nandigram # 2, Sindhwai Mata Raod, Baroda 390 004, India
E-mail: [email protected]

References:

1. Singh M. Vitamin K during infancy: Current status and recommendations. Indian Pediatr 1997; 34: 708-712.

2. Bor O, Akgun N, Yakut A, Sarhus F, Kose S. Late hemorrhagic disease of the newborn. Pediatric Int 2000; 42: 64-66.

3. Zipursky A. Prevention of vitamin K deficiency bleeding in newborns. Br J Hematol 1999; 106: 255-256.

4. Shenoi A, Rao S. Vitamin K in the newborn. Pediatrics Today 1998; 1: 333-335.

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