The wellbeing of newborns is unquestioned. In this article we summarise three key newborn medical interventions: vitamin K, vitamin D and delayed cord clamping.
Vitamin K is essential to prevent haemorrhagic disease of the newborn (HDN). This devastating and potentially fatal condition is prevented by the administration of vitamin K. For reasons of practicality, the intramuscular route is advised.
In decades past, there has been discussion that vitamin K might be linked to childhood cancer, but this has not been supported by several research studies. Oral administration has also been studied and found to be less reliable, given the dose administration is less clear and the repeated dosing interval is harder to adhere to.
For most newborn infants, they will receive intramuscular vitamin K soon after birth, often part of their neonatal check. The drug is administered into the thigh muscle, with a lower dose for preterm infants.
Vitamin K’s role mitigates the known vitamin K deficiency newborn infants are born with. Vitamin K is essential for blood clotting. Where vitamin K is not given after birth, this can present at different times: early, ‘classic’ and late onset HDN.
This is HDN within the first 24 hours.
This can present within the first week following birth, but can lead to irreversible bleeding (often around the brain) and can be fatal.
This is defined as occurring between the second week and six months of age and might have unpredictable areas and presentation of bleeding, but can also present with intracranial bleeding.
There might be instances where whanāu decline vitamin K treatment. It is important these feelings and thoughts are explored given the potentially devastating outcome for the newborn. For many parents, this might be the first decision they are making about their precious newborn.
If there is concern about consent for vitamin K it is advisable to have a discussion well before labour and delivery where thought processes are stressed. Some birthing centres will refer whanāu to their local paediatric service if consent is not achieved, which can be useful for reducing the burden on midwives.
Vitamin D is an ongoing area of scientific and clinical research. Vitamin D has important involvement in numerous biological processes and links are being made to immune function, respiratory health and growth and development. It has long been known to be important for bone health and deficiency can lead to rickets (bowed bones).
Vitamin D is formed in the skin on exposure to sunlight, but this is inappropriate for newborns who cannot safely get vitamin D from sun exposure. At present, there are established risk factors for infants to receive supplemental oral vitamin D, such as:
- maternal vitamin D deficiency
- siblings with vitamin D deficiency
- darker skin complexion
- newborns that are small for gestational age or preterm
- breastfed infants born in the lower sunlight months during winter
Fortunately, the oral administration of vitamin D is effective in addressing newborn vitamin D deficiency and is generally advised to be given until the newborn is 1 year of age when sun and food vitamin D sources increase. Helpfully, the present dose of infant vitamin D given to newborns with risk factors is one drop daily. This small amount is generally well tolerated and can be given using a dropper or by putting it onto the nipple of a breastfeeding mother prior to feeding.
Deficiencies in vitamin D are not benign and might present for an infant with bone issues (ie fractures, bowed legs) and also seizures due to hypocalcaemia, which can require intensive care support.
Delayed cord clamping
Delayed cord clamping is a more recently adopted practice following research demonstrating that it can be effective in increasing a newborn’s haemoglobin and iron stores. There is also thinking that there are other useful nutrients in the cord blood that are beneficially transferred to the infant, but are harder to measure and prove.
Low iron and haemoglobin is associated with several bad outcomes in infants including growth, feeding and developmental issues. In addition, many mothers themselves are low in iron and haemoglobin, which can affect the newborn.
The method of delayed cord clamping currently has some variation but is generally accepted to between 30 seconds to 3 minutes following birth. The exact way in which to transfer cord blood to the newborn has become more simplified and most infants will be managed with cord clamping delay alone. Previous procedures such as milking the cord and placing the newborn in a low position beneath the mother have not been supported by current research.
There is an increased risk of jaundice due to the ‘transfusion’ of blood from delayed cord clamping, but for many infants it is felt that the benefits outweigh this risk.
For newborns who require neonatal resuscitation, limiting or not performing delayed cord clamping is left to the decision-making of those caring for the mother and newborn.