Pediatrics

1. JINKA UNIVERSITY
CMHS
SAWLA GENERAL
HOSPITAL
DEPARTMENT OF
PEDIATRICS

HEMORRHAGIC DISEASE
OF NEWBORN
 2023/11/25
Bleeding disorder
1

2. PREPERED BY KAPOLE.O
2023/11/25
Bleeding disorder
2

3.  Definition of HDN
 Classification of VKDB
 Etiology, Epidemiology, PATHOPHSIOLOGY
 History and physical examination
 Investigation
 Differential Diagnosis
 Treatment & management
2023/11/25
Bleeding disorder
3

4.  Hemorrhagic disease of the newborn is a life-
threatening condition that is due to insufficient
vitamin K levels in newborns as a result of various
causes.
 In general, hemorrhage in a healthy neonate
suggests an inherited coagulation defect or immune-
mediated thrombocytopenia,
 whereas bleeding symptoms in a sick neonate are
more likely to reflect underproduction or
consumption of coagulation factors and/or platelets.
2023/11/25
Bleeding disorder
4

5. Intro….
 Hemorrhagic disorder of the newborn is a bleeding
disorder that manifests in the first few weeks of life
after delivery.
 The term hemorrhagic disorder of the newborn
encompasses all hemorrhagic diseases, i.e., due to
 vitamin K deficiency,
 trauma,
 clotting factor deficiency, etc
 Common acquired hemorrhagic disorders include
vitamin K deficiency bleeding, disseminated
intravascular coagulation and immune-mediated
thrombocytopenia. 2023/11/25
Bleeding disorder
5

6. 2023/11/25
Bleeding disorder
6

7. CLASSIFICATION OF VKDB
Early VKDB
 This can occur right after birth or up to 24
hours of age. It's caused by certain medicines
that a person may take during pregnancy such
as warfarin, phenobarbital etc
 infants can have severe bleeding, which is
usually corrected promptly by vitamin K
administration, although some have a poor or
delayed response
2023/11/25
Bleeding disorder
7

8. CONT...
Classical VKDB
 This occurs from 1 to 7 days after birth.
 It's caused by low levels of vitamin K found in
newborns most often in exclusively
breastfeeding infants who did not receive
vitamin K prophylaxis at birth.
 Severe vitamin K deficiency is also more
common in premature infants.
2023/11/25
Bleeding disorder
8

9. Cont…
Late VKDB
 This most often occurs up to 3 months after birth.
 But it can occur up to 6 months after birth.
 It can occur in a baby who did not get a vitamin K
shot at birth and who was breastfed
 usually associated with conditions that feature
malabsorption of the fat-soluble vitamin K, such
as cystic fibrosis, neonatal hepatitis, or biliary
atresia, and bleeding can be severe.
2023/11/25
Bleeding disorder
9

10. 2023/11/25
Bleeding disorder
10

11. Symptoms ofVKDB
 bleed in stool
 bleed in urine
 lumping on the head
 bleeding in the nasal area
 bleeding mucus membranes
 bruising
 excessive vomiting with blood in the vomit at time
 yellowish tinge in the eye usually of the three week
of birth
 bleeding in the penis if there has been circumcision
2023/11/25
Bleeding disorder
11

12. 2023/11/25
Bleeding disorder
12

13. COMMON CLINICAL
MANIFESTATION
 Bleeding in the
 Gastrointestinal tract
 urinary tract
 Umbilical stump after cutting the umbilical cord at
birth
 mucus membranes including nose, gum
 Scalp
 Intracranial hemorrhage
 Shock
 death
2023/11/25
Bleeding disorder
13

14. ETIOLOGY
 Vitamin K deficiency leads to decreased activity of
clotting factors, resulting in hemorrhagic disease
of the newborn.
 Adults can synthesize vitamin K in the large
intestine through the gut bacteria,
 but neonates have reduced stores of vitamin K
due to insufficient placental transfer and a sterile
gut that fails to synthesize the necessary levels of
vitamin K.
2023/11/25
Bleeding disorder
14

15.  Vitamin K deficiency can manifest in babies born to
mothers on anti-tubercular drugs (isoniazid,
rifampicin), antiepileptic (phenytoin, barbiturates, and
carbamazepine), broad-spectrum antibiotics
(cephalosporin's) or vitamin K antagonists such as
warfarin
 Infants born with malabsorption diseases such as
cystic fibrosis or hepatobiliary diseases such as biliary
atresia have also been shown to develop vitamin K
2023/11/25
Bleeding disorder
15

16. Epidemiology
 All infants irrespective of race, sex, color,
religion, national origin, etc. are known to be
affected byVitamin K deficiency bleeding
 VKDB was found to have an increased
incidence amongst male infants, breastfed
infants, and those born via spontaneous
vaginal delivery.
2023/11/25
Bleeding disorder
16

17. EPIDEMI.....
 In early VKDB, the incidence in infants who
have not received vitamin K prophylaxis
ranges from about 6% to 12%.
 In classic VKDB, the incidence has gone
down from 0.25% to 1.5% in earlier studies
to 0.01 to 0.44% in recent studies.
2023/11/25
Bleeding disorder
17

18. PATHOPHSIOLOGY
 Vitamin K is a fat-soluble vitamin that occurs in
2 forms- vitamin K1 or phylloquinone (present
in green leafy vegetables) and vitamin K2 or
menaquinone (synthesized by the gram-
negative bacteria in the intestines).
 Although vitamin K has many other roles in the
body, its major role involves the activation of
clotting factors.
2023/11/25
Bleeding disorder
18

19. PATHOPHI.....
 A deficiency of vitamin K in the body leads to
inadequate activation of these clotting factors
and hence leads to bleeding in the body, which
manifests as hemorrhagic disease of the
newborn or, more specifically, known as
VKDB.
2023/11/25
Bleeding disorder
19

20. Risk factor
 maternal factor
 premature birth
 maternal medication
 breast feeding
 Genetic factor
 liver disease
 malabsorption disorder
2023/11/25
Bleeding disorder
20

21. HISTORY &PHYSICAL
EXAMIn_
 The following points in the history that
could lead to a proper diagnosis include
 Drugs taken during pregnancy- anticonvulsants, anti-
tubercular drugs, warfarin, salicylates, etc.
 Gestation period- preterm babies are at a higher risk of
having VKDB.
 If breastfed or bottle-fed- as bottle/formula-fed infants are
at lower risk due to fortified feed with essential vitamins
and minerals.
 Place of delivery- generally home-delivered infants do not
have
 access to immediate vitamin K prophylaxis and hence are
at a greater risk.
2023/11/25
Bleeding disorder
21

22. Physical examination
 Physical findings in a patient with VKDB are
 Cephalhematoma
 Intracranial bleeding
 Intrathoracic bleeding, which can cause hemoptysis, and associated
respiratory distress
 Intra-abdominal bleeding- melaena or hematemesis
 Bleeding from the skin- petechiae present over the skin
 Bleeding from mucous membranes, including the gums, nose, etc.
 Bleeding after circumcision
 Bleeding from the umbilical stump after cutting the umbilical cord at
birth
 Bleeding from vaccination sites
2023/11/25
Bleeding disorder
22

23. CONT.....
 Intracranial bleeding is mostly associated with
late VKBD and presents with a floppy baby,
 lethargy, feeding difficulties, bulging
 fontanelles, decreased respiratory rate, altered
consciousness, convulsions, or pallor.
2023/11/25
Bleeding disorder
23

24. INVESTIGATION
 Most commonly advised laboratory tests
are:
 1. Complete blood count- will have normal
platelet levels (1.5-4 lacs/cubic mm)
 2. Clotting profile
 International normalized ratio (INR) greater
than or equal to 4
2023/11/25
Bleeding disorder
24

25. CONT ........
 Prothrombin time (PT) more than 4 times the
normal
 Prothrombin time will be increased due to
decreased activity of factor 7
 Partial thromboplastin time (PTT) will also be
increased due to decreased activity of factors
2,9 and 10
 Clotting time will be increased due to clotting
factor deficiency
 Fibrinogen levels will remain normal
2023/11/25
Bleeding disorder
25

26. CONT.....
3. PIVKA estimation- PIVKA are proteins induced
in vitamin K absence. These are evaluated by
HPLC (high-pressure liquid chromatography),
ELISA (enzyme-linked immunosorbent assay),
or immuno-electrophoresis.
4. Chest X-ray or ultrasound to determine if there
is bleeding in body cavities- intrathoracic, intra-
abdominal
5. Computed tomography (CT) and magnetic
resonance imaging (MRI) studies to evaluate
for intracranial hemorrhage
2023/11/25
Bleeding disorder
26

27. 2023/11/25
Bleeding disorder
27

28. COMPLICATION
 Intracranial hemorrhage
 Brain damage or death
 Delayed bone development
 Organ damage
 Bleeding in the stomach or intestine
 Increased cardiovascular disease
 Neurological disability
 Anemia
2023/11/25
Bleeding disorder
28

29. DIFFERENTIAL DIAGNOSIS
2023/11/25
Bleeding disorder
29

30.  Clotting factor deficiencies such as hemophilia A or
hemophilia B. Non-reversal of condition despite
administering clotting factors may help to determine
the exact cause.
 Disseminated intravascular coagulation(DIC)-
running laboratory studies will help to differentiate
between DIC and VKDB.
 Thrombocytopenia, especially maternal immune
thrombocytopenia as antibodies to platelets, can
cross the placenta and decrease infant platelet
count manifesting as purpura.
 However, in VKDB, the platelet count is generally
normal.
 For infants presenting with isolated gastrointestinal
bleed, intussusception can be a differential.
2023/11/25
Bleeding disorder
30

31. TREATMENT
&MANAGEMENT
 focus on prompt administration of vit K to infant
 In severe life threatening bleeding , immediate
blood transfusion can be given with fresh frozen
plasma to reduce the bleeding
 Intracranial shunting to relieve increased
intracranial pressure
 Regular follow up and continuous monitoring
 single intravascular(IM) dose of 1mg of vit K is
known to improve the coagulation with 1to7dayd
2023/11/25
Bleeding disorder
31

32. CONT...
 For early and classic , oral vit (2mg)dose is
repeated at 2_4weeks and at6 -8weeks
 For late o.5-1mg single dose is administrated
to infant with 6hr
2023/11/25
Bleeding disorder
32