Vitamin K and circumcision

Question 1

What are the recommendations for vitamin K delivery to the new born (9)

Answer 1

1. All newborns should receive vitamin K prophylaxis
2. Healthy newborns can receive vit K by:
   -IM 1g once off dose - preferred route
   -2mg PO x 3 doses birth, 5 days, 4 weeks (must not be later than 4 weeks)
   -If vomiting within an hr repeat PO dose
3. Newborns too unwell to have PO vit K should receive IM vit K
4. Parents should receive written info about vit K in the antenatal period
5. Prior to giving vit K the parents should give consent for this regardless of antenatal discussions
6. Protocols should exist for giving and recording vit K in birth facilities
7. Unexplained bleeding and bruising in infants is uncommon and requires immediate investigation. Parents should be informed of this
8. Currently i is understood that babies cannot receive treatment level vit K in breast milk
9. Routine audit to look at vit K deficient bleeding is to be encouraged

Question 2

Discuss the classification of vitamin K deficiency bleeding (3)

Answer 2

Early VKDB
-Occurs in first days of life
-Rare
-Confined to infants of mothers who are on meds which interfer with vit K metabolism (Anti-epileptics)
Classical VKDB
-Occurs from D1-D7
-More common in unwell babies with poor feeding or delayed onset feeding
Late VKDB
-Occurs 8 days to 6 months
-Associated with exclusively breast fed infants
-Associated with liver disease in new born or malabsorbative states
-Associated with serious ICH (30-50%)

Question 3

How effective is Vit K prophylaxis
-Early VKDB
-Classical VKDB
-Late VKDB

Answer 3

1. No RCT data to know efficacy
2. Early VKDB
   -Recommended women take supplements in last 2 weeks of pregnancy if on vit K metabolism affecting meds
   -No data on efficacy
3. Classical VKDB
   -Virtually eliminated by vit K supplementation
4. Late VKDB
   -Reduction in incidence to 0.3:100,000

Question 4

How effective is Vit K prophylaxis
-Early VKDB
-Classical VKDB
-Late VKDB

Answer 4

1. No RCT data to know efficacy
2. Early VKDB
   -Recommended women take supplements in last 2 weeks of pregnancy if on vit K metabolism affecting meds
   -No data on efficacy
3. Classical VKDB
   -Virtually eliminated by vit K supplementation
4. Late VKDB
   -Reduction in incidence to 0.3:100,000

Question 5

Discuss concerns with vit K supplementation (5)

Answer 5

1. Previous IM formulae included components linked to anaphylaxis
2. Study showed a link between IM formulae and childhood leukemia
3. Subsequent better designed studies did not support this but a non-significant trend was noted
4. PO vit K can cause gastro-upset
5. This formulation is no longer used

Question 6

Discuss male circumcision
-Incidence (1)
-Benefits of circumcision (4)
-Complications (7)
-Recommendations (4)

Answer 6

1. Incidence in NZ and Aus
   -10-20%
2. Benefits
   -Less risk of HIV
   -Less recurrent UTI
   -Less STI (Not seen in NZ data)
   -Less penile cancer
3. Complications
   -Most are minor
   -Haemorrhage
   -Fistulae formation
   -Infection
   -Urethral damage
   -Secondary phimosis
   -Psychological impact
4. Recommendations
   -Does not support routine circumcision for benefits
   -Parents choice to weigh risks and benefits and their choice should be respected
   -Appropriate unbiased info should be provided to the parent
   -The procedure should be undertaken in a safe environment by a trained practitioner