Jaundice including Vitamin K Deficiency Bleeding in the Newborn Policy

Transcription

1 This is an official Northern Trust policy and should not be edited in any way Jaundice including Vitamin K Deficiency Bleeding in the Newborn Policy Reference Number: NHSCT/10/320 Target audience: Paediatrics, Neonatology, Health Visiting, Midwives and Obstetricians Sources of advice in relation to this document: Dr H Lambrechts, Associate Specialist Neonatology Dr S Bali, Consultant Neonatologist F Brown, Head of Children s Nursing J Quigg, Advanced Neonatal Nurse Practitioner A Cubit, Advanced Neonatal Nurse Practitioner F Mc Closkey, Lead Nurse Acute Paediatrics and Neonatology P Mc Bride, Lead Public Health Nurse M Maxwell, Head of Midwifery & Gynae S O'Kane, Lead Midwife for Inpatient Services B Lagan, Clinical Midwife Specialist Replaces (if appropriate): Vitamin K Deficiency in the Newborn (legacy Causeway, Homefirst and United), Recognition and Management of Early Jaundice (Causeway) and Recognition and Management of Prolonged or Late Onset Jaundice (Homefirst and United) Type of Document: Trust Wide Approved by: Policy, Standards and Guidelines Committee Date Approved: 16 June 2010 Date Issued by Policy Unit: 26 August 2010 (Revised version updated with mandatory policy content only replaced on Staffnet May 11 following review) NHSCT Mission Statement To provide for all the quality of services we would expect for our families and ourselves 0

2 POLICY ON RECOGNITION AND MANAGEMENT OF EARLY, PROLONGED AND LATE ONSET JAUNDICE INCLUDING VITAMIN K DEFICIENCY BLEEDING IN THE NEWBORN June

3 POLICY ON RECOGNITION AND MANAGEMENT OF EARLY, PROLONGED AND LATE ONSET JAUNDICE INCLUDING VITAMIN K DEFICIENCY BLEEDING IN THE NEWBORN CONTENTS Page Introduction 3 PART ONE PART TWO PART THREE Recognition and Management of Early Jaundice 4 Appendix 1 Lighter Touch Bilirubin Chart and Results Sheet 9 Recognition and Management of Prolonged and Late Onset Jaundice 11 Appendix 2 Prolonged Jaundice Clinic Proforma 16 Appendix 3 Clinical Guideline for Prolonged Jaundice Clinic 17 Management of Vitamin K Deficiency in the Newborn 19 Appendix 4 Vitamin K Parent Information Leaflet 22 Glossary of Terms 23 References 25 2

4 POLICY ON RECOGNITION AND MANAGEMENT OF EARLY, PROLONGED AND LATE ONSET JAUNDICE INCLUDING VITAMIN K DEFICIENCY BLEEDING IN THE NEWBORN Target Audience Paediatrics, Neonatology, Health Visiting, Midwives and Obstetricians Introduction This guidance brings together the management of Early Jaundice, Prolonged Jaundice and Vitamin K Deficiency Bleeding (VKDB) in infants for the Northern Trust, to ensure a consistent Trust-wide approach to management. It emphasises the importance of recognising pathological causes of early and prolonged jaundice which require prompt investigation and intervention. In particular, a pathological cause for jaundice needs to be excluded in the first 24 to 48 hours of life (sepsis and haemolysis), and infants with prolonged jaundice need to be fully investigated to exclude pathological causes of jaundice in particular liver disease and biliary atresia. All newborn infants are at risk of VKDB and this is why all babies receive vitamin K at birth. It is important to remember that infants with liver disease are at increased risk of VKDB. 3

5 PART ONE RECOGNITION AND MANAGEMENT OF EARLY JAUNDICE Jaundice Many babies will show signs of jaundice around the third day following delivery. Providing they are alert and feeding well with good muscle tone, this will only require close observation and the jaundice will resolve spontaneously. Regular feeding is encouraged and complementary feeds are rarely necessary. Women should be advised that if their baby is jaundiced, or the jaundice is worsening, or the baby is passing pale stools, this should be reported to a healthcare professional. Jaundice in the first 24 hours, jaundice in an unwell infant, jaundice first developing after 7 days or jaundice persisting for more than 14 days requires investigation (see prolonged jaundice section). 1. Causes and types of jaundice Physiological Jaundice Physiological jaundice results from the breakdown of fetal haemoglobin, liver immaturity and increased intestinal re-absorption of bilirubin. The condition can be exacerbated by: Prematurity Excessive bruising e.g. from complicated delivery Inadequate or delayed feeding Birth asphyxia Mother s use of certain drugs e.g. diazepam. 4

6 Haemolytic Disease of the Newborn Haemolytic disease of the newborn is commonly caused by an incompatibility between the mother s and infant s blood groups. This incompatibility causes transplacental transfer of antibodies to the infant s red blood cells and in return, causes an increase in the breakdown of those red cells, putting excessive demands on the immature liver of the neonate. Haemolytic disease is caused by: ABO incompatibility Rhesus incompatibility This type of jaundice usually becomes clinically apparent within the first 24 hours of life. Infection This is caused by the extra stress placed on the immature liver by the infection inhibiting conjugation of bilirubin. There may also be reduced feeding in the sick infant. Breast Milk Jaundice Breast milk jaundice normally appears towards the end of the first week of life and improves by the end of the third week. However, a few babies will remain jaundiced for two to three months. There are many theories about the cause of breast milk jaundice, but the cause is still not really known. There is no evidence of breast milk jaundice harming the baby unless the bilirubin level reaches exchange level, mothers therefore, should be encouraged to continue breastfeeding. Other causes of jaundice need to be eliminated before the diagnosis of breast milk jaundice can be made. 5

7 Care of a Jaundiced Baby Care by the Midwife/ Nurse in the acute hospital environment includes: Close observation of the baby, particularly of its colour (which should include observation of all of the infant s body and limbs), feeding and behaviour. If a baby develops jaundice, the intensity of the jaundice should be monitored 24 hours later and systematically recorded along with the baby s overall well being with regard to hydration and alertness. A breastfed baby who has signs of jaundice should be actively encouraged to breastfeed frequently, and woken to feed if necessary 5. Breastfed babies should not be routinely supplemented with formula, water or dextrose for the treatment of jaundice 5. Artificial feeds should continue as per demand (at least four hourly). There is no evidence to support the provision of additional fluids. Obtain a serum bilirubin (has to include direct fraction) blood sample (midwife, paediatrician or Nurse Practitioner) after obtaining informed consent from the mother. NB if consent is declined the paediatrician/ nurse practitioner must be asked to review the baby. Plot the result of serum bilirubin on a Neonatal jaundice a lighter touch bilirubin chart (see Appendix 1). If the result falls into or above the phototherapy line the paediatrician must be informed. It is important to note that the lighter touch chart should only be used in well, term infants. In preterm or unwell infants the bilirubin charts (according to birth weight) should be used. If the result is just below the line or there is concern regarding the baby s condition, the paediatrician/ nurse practitioner must be informed and the test may be repeated at a later stage. Remember sepsis (including Group B Strep infection) should always be considered, especially if jaundice develops in the first 24 to 48 hours of life and should be looked for/ risk factors considered. 6

8 Where the result indicates that phototherapy is required the following management should be instigated: Inform mother/parents of serum bilirubin result and plan of action. Explain possible causes for jaundice and probable duration of phototherapy. Obtain verbal consent (see above). NB Involve an interpreter if the mother/parents do not speak or understand English. Phototherapy can be commenced (providing the paediatrician/ nurse practitioner) has been informed) To provide maximum skin exposure the baby should be nursed naked in an incubator, with the eyes covered or on a biliblanket. The baby s position should be changed frequently to ensure that all areas of the baby s skin are exposed The general condition of the baby should be frequently observed e.g. temperature, checking that eyes are covered. Observe for side effects, such as rash, diarrhoea and hypothermia. Breastfeeding should continue as per demand (at least three hourly). Supplementary feeds should not be necessary 5. Artificial feeds should continue as per demand (at least four hourly). There is no evidence to support the provision of additional fluids. SBR should be repeated daily unless otherwise indicated. The need to give phototherapy should not result in separation of the mother and baby Ensure incubators/phototherapy lights/ biliblankets are cleaned and stored when phototherapy has been discontinued as per NHSCT infection control policy. Action by Paediatrician/ Nurse Practitioner includes Explanation to the mother/parents regarding causes and outcomes. 7

9 History and physical examination of the baby and then at least daily review unless condition suggests more frequently. Blood analysis usually includes: Full blood count CRP Blood Group Direct Coombs Blood culture if indicated (especially jaundice < 24 hours age) Other investigations are done where clinically indicated Documented instruction regarding frequency of SBR tests and length of phototherapy treatment. If the bilirubin level exceeds 350umols (term baby) or 250umols (preterm baby) or continues to rise despite phototherapy, the senior paediatrician (registrar, Associate Specialist, Staff Grade or Consultant) must be informed. 8

10 APPENDIX 1: Neonatal Jaundice Bilirubin Chart Baby s Name (or affix ID Label): DOB/ Unit No: 500 Age 1 Day 2 Days 3 Days 4 Days 5 Days 6 Days 7 Days Consider Exchange Transfusion (TERM) 450 Bilirubin (µmol/l) Consider Exchange Transfusion (Pre-Term) Phototherapy (PRE-TERM) Phototherapy (TERM) Hours REF: Finlay HVL, Tucker SM Neonatal plasma bilirubin chart. Arch Dis Child.53: p90-91 cited in: Meberg A Hyperbilirubinaemia a controversial topic. Experiences with new guidelines for phototherapy and exchange transfusion. Nor J Epidemiol 7(1): p (Modified from the Hillingdon Hospital Bilirubin Chart, England). 9

11 Neonatal Jaundice: Bilirubin Result(s) and Management Date of Birth / / Time of Birth hrs Gestational Age + wks Birth Weight Kgms Method of Feeding Baby s Blood Group (If Known) Rh Direct Coombs Neg. Pos. Mothers Blood Group Rh Antibodies No Yes (specify) Date Time Taken Age (hrs) *SBR Result Action / Management / Comments Sig. *Plot SBR result on Bilirubin Chart Overleaf 10

12 PART TWO MANAGEMENT OF PROLONGED AND LATE ONSET JAUNDICE 1. DEFINITION Prolonged jaundice is defined as jaundice persisting beyond two weeks of age in term infants and three weeks in pre-term infants (Children s Liver Disease Foundation). 2. CAUSES There are many causes for jaundice in infants. It is important to determine the ratio of conjugated (direct) to unconjugated (indirect) bilirubin to exclude obstructive jaundice or hepatitis syndrome. A raised conjugated bilirubin could be an early sign of biliary atresia especially when associated with pale stools and dark urine. Causes of unconjugated jaundice: Breast milk jaundice Physiological jaundice Prematurity Hypothyroidism Haemolysis: spherocytosis Sepsis Gastro-intestinal obstruction: pyloric stenosis Inherited disorders of bilirubin metabolism: Gilbert s Syndrome, Crigler-Najjar Syndrome Causes of conjugated jaundice: Biliary obstruction: biliary atresia Infection: Urinary tract infection (may present with jaundice alone), viral, hepatitis, congenital TORCH Chromosomal abnormality: Turner s, Trisomy 18 and 21 Syndromes Inherited and metabolic disorder: Cystic Fibrosis, Galactosaemia Note: Breast milk jaundice is the commonest reason for prolonged jaundice in the newborn. The jaundice can persist for several weeks after birth. It is not a contraindication to breastfeeding. However, if jaundice persists beyond two weeks in well term infants or three weeks in preterm infants referral must be made to the Prolonged Jaundice Clinic in Antrim/ Paediatrician in Causeway or Mid Ulster Hospital 11

13 3.URINE AND STOOL COLOUR Midwives, Nurses and Health Visitors should be aware of the importance of urine and stool colour: Normally a baby s urine is colourless Persistently yellow urine which stains the nappy can be a sign of liver disease Normally a baby s stools are green or yellow Persistently pale coloured stools may indicate liver disease A jaundiced baby with pale stools and yellow urine can appear completely healthy. The baby may have a potentially lethal liver disease. This guideline accepts that the interpretation of the colour of stools can be subjective. The colour chart below will help to overcome this problem. A healthy baby s stools can be any of these colours. Do not worry about green stools. Breast-fed babies often pass watery stools. sudden change to frequent watery stools of any colour may mean the baby is unwell. In babies with liver disease, A the stools may be one of these colours. Do not worry about one or two that look unusual. 4. THE ANTENATAL PERIOD Experience has shown that when baby jaundice is explained in the antenatal period, parents are less anxious if their baby becomes jaundiced. In addition, they are knowledgeable about the course of action to be taken in the event of prolonged jaundice i.e. beyond two weeks of age in a term infant and three weeks pre-term. Midwives and Health Visitors should explain ordinary baby/physiological jaundice to all parents and inform parents about the management of prolonged jaundice. 12

14 5. FIRST POSTNATAL VISIT AND ASSESSMENT BY MIDWIFE AND/OR HEALTH VISITOR Every baby should be checked for jaundice by looking at the sclera of the eyes and skin colour. The presence of jaundice in an infant should always be recorded in the relevant midwifery/health visiting record and PCHR. On transferring a baby from the midwife to health visitor the CHS4 or Community Midwife s Report to Health Visitor form should state that an assessment for the presence of jaundice has been carried out. If the baby is jaundiced, stools and urine should be checked and seen by the health visitor and/or midwife. A baby s urine should be colourless. If yellow, this should be investigated. Stools should be pigmented yellow or green. See chart on page 3. If pale or clay-coloured this should be investigated. If the stools and urine in a jaundiced baby are abnormal in colour, the baby should be referred to a paediatrician immediately. 6. PROLONGED JAUNDICE Action in the event of prolonged jaundice Health professionals must seek medical advice as a priority for infants who present with prolonged jaundice and are unwell. If the baby is well, referral should be made to the Prolonged Jaundice Clinic in Antrim/ Consultant Paediatrician in Causeway/ Paediatrician Mid Ulster Ambulatory Unit by following the referral process guideline. REFERRAL GUIDELINE When the health professional assesses that the well infant is presenting with prolonged jaundice, an explanation of the investigation procedure and the parent information leaflet will be given to the parent/carer. They will be advised that a referral will be made for a clinical examination and further investigation. A minimum of two consultations will be required. The Advanced Neonatal Nurse Practitioners (ANNP) will run the Well Infant with Prolonged Jaundice Clinic supported by Medical Staff at the Antrim Hospital site. In the Mid Ulster area, infants can be referred to the Ambulatory Unit, Mid Ulster Hospital. In the Causeway area, infants are referred to the Consultant Paediatrician. 13

15 Once referred, investigation and management of well infants with prolonged jaundice will follow the Child Health Directorate Guideline. (Appendix 3). Referral Process for Antrim facility 1. The Referrer to telephone the Neonatal Unit and ask for Alison Cubitt, ANNP or Jackie Quigg, ANNP. If not available, ask for Designated Contact for the Prolonged Jaundice Clinic. 2. Give verbal referral to include: infant s name, address, date of birth, parents/carers name and contact details, referrer name and contact details and GP name and contact details. 3. The Midwifery/Health Visiting contact and referral to be documented in the Midwifery/Health Visiting Records and PCHR. Feedback to Referrers from Clinic 1. The Referrer and GP will receive a copy of the Clinic Proforma (Appendix 1) supplying relevant details of the outcome of the investigation for prolonged jaundice and any subsequent follow-up. 2. When it is necessary to admit an infant for further investigation, the Referrer will be informed. It is the responsibility of the Referrer to inform the GP. 3. When a clinic appointment has been made for a child, and the child does not attend for investigation, the ANNP/ Paediatrician will contact the Referrer to follow up with the parent/carer as a matter of priority. 4. If the parent/carer refuses to attend or repeatedly fails to attend clinic appointments, the Referrer will document this in the midwifery/health visiting records, inform the infant s GP in writing and inform their line manager and child protection nurse specialist. Further action will be determined in consultation with the Referrer, GP, ANNP, Paediatrician and the parents/carers based on the best interests of the child (The Children NI Order, 1995). 14

16 5. Early Identification Flow Chart Assessment Skin colour/sclera of eyes Urine/stool colour Document Unwell baby referral to Paediatrician Well Baby with Jaundice Term >2 Weeks old Pre-Term >3 Weeks old Paediatric Ambulatory Unit Explanation to Parents/carers Parent Information Leaflet Telephone referral Document Refer to Prolonged Jaundice Clinic Antrim Explanation to Parents/Carers Parent Information Leaflet Telephone referral to Neonatal Unit Document Examination Investigation Causeway Paediatric OPD Explanation to Parents/carers Parent Information Leaflet Telephone referral Document Investigations Normal Investigations Abnormal Does not attend Feedback to Referrer Follow up by Referrer Feedback to Referrer Feedback to Referrer Clinic Declined No further action Paediatric Review Document & Inform GP/Line Manager/CPNS Further Action based on Outcome of Professional & Parental Consultation 15

17 Appendix 2 Prolonged Jaundice Clinic (Well Babies) Checklist for History, Examination and Results Name and Address: (Affix label) Contact Details (Where Applicable): Midwife: Health Visitor:... Parent/ Guardian:... GP: Bloods/ Investigations requested: Date of Clinic Visit: Age: Results: Current Weight: Birth Weight: Feeding Details: Breast / Bottle Vitamin K Status: Stool Colour: Dark / Pale Family history: Jaundice / Anaemia / Bleeding Disorder Detail: Urine Colour: Light / Dark / Changing Further Action Required? Yes/ No Detail: Other relevant History: Examination Evidence of Dehydration?... Hepatosplenomegaly?... Evidence of Bleeding or Bruising?... Other relevant findings: Signature for initial assessment; Signed.. Print Name and Date Review?... Copied to Community Midwife/ HV?... Copied to GP?... Signature for Results Action: Signed... Print Name and Date 16

18 Appendix 3 Child Health Directorate Prolonged Jaundice 1.0 INTRODUCTION This guideline is intended to support medical, nursing and midwifery practitioners in the management of infants with Prolonged Neonatal Jaundice 1.1 The Aims of the guideline are: To allow early detection of pathological causes of prolonged jaundice which require prompt intervention such as biliary atresia To be aware that jaundiced babies are at increased risk of haemorrhagic disease of the newborn due to Vitamin K deficiency 1.2 Prolonged jaundice is defined as jaundice > 2 weeks in term infants and > 3 weeks in preterm infants. 1.3 This guideline should be read in conjunction with Policy on Recognition and Management of Early, Prolonged and Late Onset Jaundice including Vitamin K Deficiency Bleeding in the Newborn. 2.0 CLINIC ASSESSMENT and INVESTIGATION of Well Breastfed Infant 2.1 Assessment and documentation will be as set out in the Clinic Proforma (Appendix 1). 2.2 Though breastfeeding is the most common reason for prolonged jaundice in the newborn, it remains important to remember that this is a diagnosis of exclusion. Therefore it is important to rule out other potentially serious underlying causes. 2.3 Well breastfed infants will be assessed using the clinic proforma. If history and examination are typical of breast milk jaundice and the infant appears well, a split bilirubin test only will be required. 2.4 If Total SBR < 250 and Direct SBR < 20% of total, no further immediate intervention/ investigation will be required although the infant will be reviewed in one to two weeks for clinical assessment and repeat SBR if appropriate. This is to make sure jaundice is settling. If this is not the case, further management will be discussed with a senior Paediatrician and investigation for unconjugated jaundice considered. 2.5 If conjugated fraction is > 20% and/ or there are signs of obstructive jaundice (dark urine, pale stools), discuss management with a Senior Paediatrician and consider hospital admission, if appropriate, for investigation of Conjugated Hyperblirubinaemia/ Neonatal Cholestasis. 17

19 3.0 CLINIC ASSESSMENT and INVESTIGATION of Well Bottle-fed Infant 3.1 As bottle-fed infants with prolonged jaundice are more likely to have a pathological cause, they will receive a split bilirubin but also a first line prolonged jaundice screen (to include FBC, LFT, Urine Culture). 3.2 Should infant on assessment be unwell or any immediate concerns identified, care should be discussed with senior medical staff and, if appropriate, infant admitted to hospital for further management. 3.3 If Total SBR < 250 and Direct SBR < 20% of total, no further immediate intervention/ investigation will be required although the infant will be reviewed in one to two weeks for clinical assessment of jaundice as well as review of first line screen results and repeat split SBR if appropriate. If results are abnormal or bilirubin levels not settling, further management will be discussed with a senior Paediatrician and investigation for unconjugated jaundice considered. 3.4 If conjugated fraction is > 20% and/ or there are signs of obstructive jaundice (dark urine, pale stools), discuss management with a Senior Paediatrician and consider admission to hospital for the investigation of conjugated Hyperbilirubinaemia/ neonatal Cholestasis. 4.0 RESULTS ACTION 4.1 The medical staff or nurse practitioner will obtain blood results the morning after consultation and enter these on the Clinic Proforma. 4.2 Copies of the Proforma will be forwarded to the Referrer and GP and original will be retained in the infant s chart. 4.3 Abnormal results requiring action will be discussed with senior medical staff for further management as above. 5.0 REVIEW 5.1 All infants will be reviewed at least once to ensure jaundice continues to settle. 5.2 Appointment for the following one to two weeks will be issued at the first visit. 5.3 Results of this second visit will be communicated to the referrer/ GP via an Outpatient Attender Sheet. 5.4 Should further follow-up be required, this will be arranged through the appropriate Consultant. 18

20 PART THREE MANAGEMENT OF VITAMIN K DEFICIENCY IN THE NEWBORN Rationale: Available evidence indicates that Vitamin K prophylaxis is effective and prevents significant morbidity and mortality due to Vitamin K Deficiency Bleeding (VKDB) in newborn babies. VKDB may present in one of three ways: - Early onset within the first 24 hours of birth. - Classical within the first week after birth and typically presenting with oral, umbilical, rectal or circumcision bleeding. - Late onset after the first week, almost exclusively in breast fed infants and often in those with liver disease or malabsorption. Intracranial bleeding occurs in more than 50% of babies who are diagnosed with late onset VKDB. Multiple large studies have not shown any detrimental effects. In particular the suggestion made in an earlier study (Golding et al, 1992) of a link between intramuscular (IM) Vitamin K and childhood cancer was never repeated. A review of data from the UK Children s Cancer Study Group in 2003 concluded that Vitamin K is not associated with childhood cancer or leukaemia whether it is given by injection or by mouth. Objective: To prevent babies from developing VKDB. 19

21 Policy: Copies of the Vitamin K leaflet must be given to all women at their booking visit. Midwife must record in Antenatal checklist and sign. Verbal consent must be obtained and documented in the intrapartum section of the mother s obstetric record prior to the administration of Vitamin K after birth. The intramuscular (IM) route of administration is strongly recommended (NICE Clinical Guideline 37, July 2006) and clinical practice must reflect this. This is especially important in babies at particular risk of VKDB (birth asphyxia or bleeding problems, those born to mothers with liver disease or taking enzyme inducing anticonvulsant drugs) Please note that separate guidelines exist for Very/ Extremely Low Birth Weight (VLBW/ ELBW) infants in the neonatal unit setting. The dose of intramuscular vitamin K is as follows: o Babies 36 weeks gestation and after: 1mg (0.1ml) IM at birth of Phytomenadione 2mg/0.2ml (Konakion MM Paediatric) o Babies less than 36 completed weeks gestation: 0.5mg (0.05ml) IM at birth of Phytomenadione 2mg/0.2ml (Konakion MM Paediatric) Where as a result of informed parental choice the baby is to receive oral Vitamin K the dose is as follows: o Formula-fed babies: Two doses of Phytomenadione 2mg/0.2ml (Konakion MM Paediatric), First dose: 2mg (0.2ml) orally at birth. Second dose: 2mg (0.2ml) orally at one week of life. o Exclusively breast fed babies: Three doses of Phytomenadione 2mg/0.2ml (Konakion MM Paediatric), First dose: 2mg (0.2ml) orally at birth. Second dose: 2mg (0.2ml) orally at one week of life. Third dose: 2mg (0.2ml) orally at 4 to 6 weeks of life. The 1st dose of oral vitamin K must be given at birth by the Midwife attending the delivery following verbal consent as outlined above for IM vitamin K. The 2 nd dose must be given at 1 week of life by the Community Midwife (or the postnatal ward/ Neonatal Unit should the infant still be in hospital). The 3 rd dose (if applicable breast fed infants) must be administered by the infant s Health Visitor. The oral Vitamin K must be prescribed and dispensed prior to discharge from hospital. Parents or guardians who make an informed decision not to give their babies Vitamin K in any form must be given information by a paediatrician of middle grade level or above about the early warning signs of VKDB/ Haemorrhagic 20

22 Disease of the Newborn as this can be important in obtaining early treatment to reduce the severity of the disorder. This parental choice and subsequent discussion with the paediatrician must be carefully documented in the medical notes, noting in full the information given to the parents. The method of administration and the dosage of vitamin K must be recorded on the Delivery Record from where it is transferred to the Neonatal Discharge Form (CHS3b). 21

23 VITAMIN K An Essential vitamin for all babies Guidance notes for parents What is Vitamin K? Vitamin K helps the blood to clot and helps to prevent serious bleeding occurring. Why does my baby need Vitamin K? When a baby is born he/she has very low levels of Vitamin K and needs to be given supplements to boost these levels. Low levels of Vitamin K can lead to a rare but serious blood disorder called Vitamin K Deficiency Bleeding of the Newborn (also called VKDB), occurring in about 1:1000 babies not given this essential vitamin. How is this essential vitamin given? Babies receive their Vitamin K by a single intramuscular injection. This is the easiest and most reliable way to give Vitamin K to babies and will provide adequate protection. It is also the method recommended by National Guidelines ( Should you have any concerns about this injection, please discuss it with your Midwife or Doctor. What happens if I don t want my baby to have the injection? Vitamin K can be given by mouth although this is a less effective way of giving Vitamin K as several doses by mouth are essential to give enough protection. The choice about whether your baby has the injection is yours our role is to give you enough information to allow you to make the right decision for you and your baby. Giving Vitamin K to your baby is your choice should you decide not to give your baby Vitamin K at all, you will need to speak to a senior Paediatrician (Baby Doctor) to discuss this and to alert you to the possible danger signs. What happens if my baby does not get Vitamin K? A baby who isn t given Vitamin K is at risk of serious bleeding. The baby can bleed into any part of his/her body and this can result in serious illness or even death within the first few months of life. Are there any risks? Multiple large studies have not shown any detrimental effects. In particular, a suggestion made in an earlier study of a link with childhood cancer was never repeated. Also, a review of data from the UK Children s Cancer Study Group in 2003 concluded that Vitamin K is not associated with childhood cancer or leukaemia whether it is given by injection or by mouth. 22

24 Glossary of Terms Preterm - Defined as infants born < 37 completed weeks gestation. Bilirubin Red cell destruction releases unconjugated (indirect) bilirubin. This is conjugated in the liver to make it water soluble and therefore makes excretion possible in bile. It is then converted to stercobilinogen in the gut and excreted in the stool or reabsorbed and excreted in the urine as urobilinogen. Any obstructive process (like biliary atresia) or liver disease (like neonatal hepatitis syndrome) will therefore lead to overspill of conjugated (direct) bilirubin into the blood. Biliary atresia The biliary duct between the liver and the intestine fail to develop and is completely blocked this leads to conjugated jaundice. Early recognition is very important for surgery to have a chance of being successful late recognition leads to liver failure and need for liver transplant. Breast milk jaundice This is the most common cause of unconjugated prolonged jaundice. It might be attributed to steroid inhibitors present in breast milk which are thought to inhibit the action of glucoronyl transferase and thus the conjugation of bilirubin is delayed. Physiological jaundice Most babies get some degree of jaundice after 48 hours this is due to many factors: Reduced red cell survival, polycythaemia, bruising, enterohepatic circulation, reduced liver enzyme activity, etc. Jaundice, however, usually does not persist beyond 2 weeks of life in term infants and 3 weeks in preterm infants. Hypothyroidism This is due to congenitally underactive thyroid gland it leads to unconjugated (indirect) jaundice. It is tested for on the newborn bloodspot test. If not recognised, it can lead to growth failure, learning difficulties and developmental problems and therefore should not be missed. Haemolysis This is increased breakdown of red cells (for a variety of reasons) which can lead to unconjugated jaundice. Spherocytosis This is a genetic disorder of the red cell membrane leading to an abnormally shaped red cell which can cause increased breakdown of red cells therefore leading to anaemia, unconjugated jaundice and enlargement of the spleen. It is more common in people of Northern European descent. Sepsis General term referring to infection in the bloodstream. Pyloric stenosis This is a condition where the muscle at the outlet of the stomach (the pylorus) thickens and causes obstruction of the flow of milk from the stomach to the gut. It is slightly more common in boys, usually presents at 4 to 6 weeks of age with projectile vomiting and there is often a family history. Gilbert s Syndrome Rare, benign inherited form of non-haemolytic unconjugated Jaundice. Crigler-Najjar Syndrome Rare form of congenital, non-haemolytic unconjugated jaundice (Autosomal recessive). TORCH Congenital infection Toxoplasmosis, Rubella, Cytomegalovirus, Herpes may lead to microcephaly, rashes, hepatosplenomegaly, neonatal jaundice, etc. 23

25 Turner s Syndrome Chromosomal abnormality where, in a female, there is the loss of one X chromosome leading to short stature, infertility and sometimes learning difficulty. Trisomy 13, 18 and 21 Synonymous for Patau, Edwards and Down s Syndrome. Cystic Fibrosis CF is the UK s most common, life-threatening inherited disease. One in 20 people in Northern Ireland is a carrier. As its inheritance is autosomal recessive, when both parents are carriers, risk of their baby being affected is 1:4. CF mainly affects the lungs and digestive system, but can present in the neonatal period with prolonged jaundice and failure to thrive. Galactosaemia Another autosomal recessive condition caused by the absence of the enzyme galactose- 1 phosphate uridyl transferase. It has a UK incidence of 1/ Affected infants are normal at birth, but on commencement of milk feeds the majority suffer: jaundice, vomiting, diarrhoea, failure to thrive. 24

26 References 1. Children s Liver Disease Foundation (2007) Yellow Alert Jaundice Protocol, Birmingham. 2. Keffler S, Kelly DA, Powell JE, Green A. Population screening for neonatal liver disease: a feasibility study. J Pediatr Gastroenterol Nutr. (1998) Sep;27(3): McKiernan PJ, Baker AJ, Kelly DA. The frequency and outcome of biliary atresia in the UK and Ireland. Lancet. (2000) Jan 1; 355(9197): Davenport M, De Ville de Goyet J, Stringer MD, Mieli-Vergani G, Kelly DA, McClean P, Spitz L. Seamless management of biliary atresia in England and Wales ( ). Lancet. (2004) Apr 24;363(9418): Routine postnatal care of women and their babies; NICE clinical guideline 37; July BNF for Children Roberton s Textbook of Neonatology; Fourth Edition Royal Jubilee Maternity Service Vitamin K Policy; 2006 Equality, Human Rights and DDA The policy is purely clinical/technical in nature and will have no bearing in terms of its likely impact on equality of opportunity or good relations for people within the equality and good relations categories. Alternative formats This document can be made available on request on disc, larger font, Braille, audiocassette and in other minority languages to meet the needs of those who are not fluent in English. Sources of Advice in relation to this document The Policy Author, responsible Assistant Director or Director as detailed on the policy title page should be contacted with regard to any queries on the content of this policy. 25