Wednesday, May 16, 2012

Vitamin K


As some of you may know I am in nursing school. Sometimes I notice things that are technically not right:

It's important to be technically right in text books because if your not, misunderstanding of concepts worded improperly can cause serious medical discrepancies. I start L&D next semester and am doing some of my drug cards ahead of time. More specifically I am working on vitamin K. I have a Davis's drug Guide for nurses 12th edition by F.A. Davis. On page 1026 under the Distribution of vitamin K it says "does not enter breast milk."

?


This came up as suspicious to me because I have been doing some research on vitamin K for a while. So I went to the big wig on medications and the mothers milk- he is in fact the author of Medications and the Mothers' Milk- Thomas W. Hale PhD. He list of credentials are quite long and he has a very impressive web site and forum that is a great resource for nursing mothers.


And in my wishlist of conferences I wish I could attend he is lecturing at a great looking on one on September 12-14th 2012 in San Antonio, Texas.

But since I am getting sidetracked here is what Medications and the Mothers' Milk says about vitamin K:

Vitamin K1 is often used to reverse the effects of oral anticoagulants and to prevent hemorrhagic disease of the newborn (HDN).[1,2,3] The use of vitamin K has long been accepted primarily because it reduces the decline of the vitamin K dependent coagulation factors II, VII, IX, and X. A single IM injection of 0.5 to 1 mg or an oral dose of 1-2 mg during the neonatal period is recommended by the AAP. Although controversial, it is generally recognized that exclusive breastfeeding may not provide sufficient vitamin K1 to provide normal clotting factors, particularly in the premature infant or those with malabsorptive disorders. Vitamin K concentration in breast milk is normally low (<5-20 ng/mL), and most infants are born with low coagulation factors (30-60%;) of normal. Although vitamin K is transferred to human milk, the amount may not be sufficient to prevent hemorrhagic disease of the newborn. Vitamin K requires the presence of bile and other factors for absorption, and neonatal absorption may be slow or delayed due to the lack of requisite gut factors.

Hale, Thomas Wright. Medications and Mothers' Milk. Amarillo, TX: Hale Pub., 2010. Print.

So unlike my nursing (medical not maternal) book, Doctor Hale says The Vitamin does seem to pass through the breast milk, but in small amounts. He seems like a higher authority on the matter of breast milk than Mr. Davis.

So that question was answered, but the plot thickens here:

The whole reason that statement about it not passing through breast milk caught my eye was because it clearly shows a biased attitude toward the idea that breastfed babies are not receiving "enough" vitamin K via breast milk. And Doctor Hale's book still leaves the answer ambiguous (for me and my technicality problem at least).

To better understand the matter you have to understand the controversy:

The controversy on the matter is this: There was a study that linked the routine vitamin K shot given right after birth to childhood leukemia.

The Baby Bond.com covers this idea a little more and cites all the studies. It really breaks down the physiology in interesting ways.


http://thebabybond.com/VitaminKinjectORnot.html

My personal favorite part in their article is "While breastfed infants demonstrate lower blood levels of vitamin K than the "recommended" amount, they show no signs of vitamin K deficiency (leading one to wonder where the "recommended" level for infants came from)."
This is the same question my husband and I both came to independently. But I digress...

The thought is if you can achieve an optimal supplementation without the vitamin K IM shot in the neonate, then you can achieve a balance of decreasing risk of hemorrhagic disease in the newborn and decreasing the possible side effect of cancer.

the site breaks down the numbers at this:"Extracting data from available literature reveals that there are 1.5 extra cases of leukemia per 100,000 children due to vitamin K injections, and 1.8 more permanent injuries or deaths per 100,000 due to brain bleeding without injections."

So really if you are deciding injection alone vs none it's kind of a pick your very rare chance of it happening poison. But if you neglect to notify the pediatric nurses of your birth plan choices, standard of care will default to giving the injection

It is important to note thebabybond.com only addresses late vitamin K deficiency bleeding, meaning the onset is from 2 to 12 weeks of age in their "What is the concern? " section when they start: "The problem of bleeding into the brain occurs mainly from 3 to 7 weeks after birth" 
There is also early vitamin K deficiency bleeding (VKDB) of the newborn that happens with onset of birth and seems to be the most critical in the first 24-72 hours this is not addressed in anything I have read here. (This is important when You read my correspondence with Doctor Hale.)

On the flip side of things the American Academy of pediatrics released this info:


This basically concludes that the link to the vitamin K shot and cancer is very insignificant if at all present. However I think to be definitive more studies done. I would like a study of babies that had the vitamin K shot with two separate groups of breastfed vs. non breastfed and their rates of cancer. I would also like a study done on preemies. I'm also not a fan of the only 3 recommendations that this study gives:
  1. Vitamin K1 should be given to all newborns as a single, intramuscular dose of 0.5 to 1 mg.16
  2. Additional research should be conducted on the efficacy, safety, and bioavailability of oral formulations and optimal dosing regimens of vitamin K to prevent late VKDB.
  3. Health care professionals should promote awareness among families of the risks of late VKDB associated with inadequate vitamin K prophylaxis from current oral dosage regimens, particularly for newborns who are breastfed exclusively. 
Why do all the recommendations push more medications? Is it possibly because medications are more profitable than educating an unhealthy society on adequate nutrition? The question you have to ask is why would our infants have an innate deficit of vitamin K to begin with? Is it possible this day in age that we may not have a diet optimizing our consumption of vitamin K especially when it's found in green leafy vegetables? I find it hard to believe that God's original design was not the optimal design here. I would be more for suggestions of breastfeeding moms understanding their increased dietary intake demands (kind of like that whole vitamin D ordeal). Also for mothers being able to recognize intestinal malabsorption defects so as to know when intervention is truly necessary. I would also like more research on "normal" vitamin K levels and more explanation on where the current numbers are actually coming from.

My conclusion: 
Educate yourself and make the decision you need to make but just read everything with a skeptical eye and make sure you look at how the studies are done from all angles.

More Food for thought: 

Thomas Hale is also a professor at Texas Tech University School of Medicine and I actually asked him some questions in his very useful forum (see link above) and received some great resources and replies directly for him. I've decided he's pretty awesome. If you're interested here is our correspondence. You can also just look these up in his forum under vitamin K:

Me:

I'm not sure if this is the right venue for this. I am just a mother trying to ask a question about Vitamin K supplementation in breast milk and this is the only thing I found close to being a way to contact anyone knowledgeable on the topic with regards to my question.


In Medications and Mothers' Milk 13th edition by Thomas W. Hale PhD page 766 reads " Although controversial, it is generally recognized that exclusive breastfeeding may not provide sufficient Vitamin k1 to provide normal clotting factors...vitamin K concentration in breast milk is normally low...Although vitamin K is transferred in human milk, the amount may not be sufficient to prevent hemorrhagic disease of the newborn."


but I just read:


"Breastfed infants may benefit from increased maternal vitamin K intake during lactation as well. a supplement of 5mg of vitamin K to lactating mothers increases the concentration of this nutrient in human milk and significantly increases infant plasma vitamin K (Nishiguchi et al., 2002; Greer, 2001a)...The Danish practice of parents providing weekly oral doses of vitamin K for the first 3 months for primarily breastfed infants revealed high parental participation and no reports of hemorrhagic disease in an 8-year period (Hansen et al., 2003)."


Lauwers, Judith, and Anna Swisher. Counseling the Nursing Mother: A Lactation Consultant's Guide. 5th ed. Sudbury, MA: Jones & Bartlett Learning, 2011. 194. Print.


Is there some flaw in the mentioned studies that makes them discredited? Does anyone know of any further studies that I can read to further be educated on this topic?
Hale:


The problem with this statement is that virtually all hemorrhagic disease of the newborn occurs within 24 to 48 hours of birth. Even the oral administration of Vitamin K to the infant is not considered fast enough. Thus all the pediatric organizations generally recommend the use of IM injections immediately after birth.


Thereafter, supplementation of the mom would probably help a little, but NOT during this critical 24 hour period.


Below is from my 15th edition of Medications and Mothers Milk, 2012.


Tom Hale Ph.D.




----------------------------


Vitamin K1 is often used to reverse the effects of oral anticoagulants and to prevent hemorrhagic disease of the newborn (HDN).[1,2,3] The use of vitamin K has long been accepted primarily because it reduces the decline of the vitamin K dependent coagulation factors II, VII, IX, and X. A single IM injection of 0.5 to 1 mg or an oral dose of 1-2 mg during the neonatal period is recommended by the AAP. Although controversial, it is generally recognized that exclusive breastfeeding may not provide sufficient vitamin K1 to provide normal clotting factors, particularly in the premature infant or those with malabsorptive disorders. Vitamin K concentration in breastmilk is normally low (<5-20 ng/mL), and most infants are born with low coagulation factors (30-60&#37;) of normal. Although vitamin K is transferred to human milk, the amount may not be sufficient to prevent hemorrhagic disease of the newborn. Vitamin K requires the presence of bile and other factors for absorption, and neonatal absorption may be slow or delayed due to the lack of requisite gut factors.


Vitamin K2 (menaquinones, menatetrenone) is more orally bioavailable Vitamin K. It is derived from various foods including meat, eggs, dairy, and natto. There have been some suggestions that K2 may prevent osteoporosis. 

 

Me:

Thanks for the quick reply. I am so thankful for all your research and dedication. Could prophylactic supplementation by the mom in the last weeks of pregnancy correct for those critical 24-48 hours after birth? Does Vitamin K pass through the placenta more readily than into the breast milk?
Hale:
The oral use in mom may increase the Vitamin K levels in the infants, but in the article below, the coagulation factors in the infant were not apparently increased.


Because this syndrome is so horrible when it occurs, I don't think you would ever want try oral use over the proven IM used postpartum.


Tom Hale Ph.d






Pediatrics. 1989 Dec;84(6):1045-50.
Maternal administration of vitamin K does not improve the coagulation profile of preterm infants.
Kazzi NJ, Ilagan NB, Liang KC, Kazzi GM, Poland RL, Grietsell LA, Fujii Y, Brans YW.
Source
Department of Pediatrics, Wayne State University School of Medicine, Detroit, Michigan.
Abstract
The effect of maternal administration of vitamin K1 on cord blood prothrombin time, activated partial thromboplastin time, activity of factors II, VII, and X, and antigen levels of factors II and X in infants less than 35 weeks' gestation was evaluated. Pregnant women in preterm labor were randomly assigned to receive 10 mg of vitamin K1 intramuscularly or no injection. If delivery did not occur in 4 days, the dose of vitamin K1 was repeated. Women who continued their pregnancy 4 days beyond the second dose received 20 mg of vitamin K1 orally daily until the end of the 34th week of gestation. The birth weights of infants ranged from 370 to 2550 g and gestational age ranged from 22 to 34 weeks. The prothrombin time, activated partial thromboplastin time, factors II, VII, and X activity, and factors II and X antigen levels were not statistically different in either group of infants. Intraventricular hemorrhage occurred in 25 of 51 control infants and 25 of 47 vitamin K-treated infants. More control infants had grade III intraventricular hemorrhage on day 1 (P = .032), but on day 3 and 14 of life, the severity of intraventricular hemorrhage was comparable in both groups. Infants in whom an intraventricular hemorrhage developed were significantly smaller, younger, and more critically ill than infants without intraventricular hemorrhage. Administration of vitamin K1 to pregnant women at less than 35 weeks' gestation does not improve the hemostatic defects nor does it reduce the incidence or severity of intraventricular hemorrhage in their infants.
PMID: 2587133 [PubMed - indexed for MEDLINE]


Me:
Thank your for taking your time to explain this. I am still trying to understand it. You say in the 15th edition of Medications and the Mothers' Milk that "most infants are born with low coagulation factors (30-60&#37;;) of normal."


Where is the normal &#37; for the coagulation factors coming from? Is that a normal adult's level or is there some age adjusted table that can be referenced? And where do they draw data to establish a normal level? Are there studies which establish a dangerous level or threshold below which one is at a significantly increased risk for hemorrhagic disease?
Hale:
Blood chemistry values are all evaluated according to age.  I'm sure that the 30-60 percent was 
determined in older infants following supplementation with vitamin K.  
 
Tom Hale Ph.D.


 _______________________
I'll be sure to add any updates on this that I find blogworthy in the meantime enjoy this overwhelming amount of information to ruminate on. It's not as cut and dry and one would hope for.



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