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In the outpatient clinic, a 2-month-old baby suddenly cries and vomits, and the physical examination shows small red spots or skin ecchymosis on the palate. The disease is not uncommon in clinical practice, often with hidden onset, manifested as sudden intracranial hemorrhage, neurological sequelae such as cerebral palsy after rescue, and even death in severe cases, which should be paid attention to.
Vitamin K deficiency bleeding (VKDB) classification
There are three types according to the age of onset:
Early-onset types are rare. Due to the prophylactic promotion of vitamin K1 injection immediately after birth, the classic type has become very rare in recent years. Compared with the former, the late-onset type is more common, and intracranial hemorrhage accounts for about 50% of the late-onset type, and the mortality and disability rates are high.
Clinical manifestations of late-onset VKDB
The late-onset type is mostly insidious and without aura, and the main manifestations are crying, irritability, irritability, lethargy, vomiting, screaming, convulsions, etc. Sudden intracranial hemorrhage is often the first symptom, with acute intracranial hypertension manifesting, and physical examination may show bulging fontanelles, pale skin and mucous membranes, bleeding spots or ecchymosis, and bleeding from nostrils or umbilicus.
Diagnosis of VKDB
Combine history and clinical findings with the following laboratory tests.
The international normalized ratio (INR) ≥ 4 times the standard value, and the prothrombin time (PT) ≥ 4 times the standard value, and at least one of the following:
- 1. Platelet count is normal or elevated, fibrinogen is normal, and there are no fibrin degradation products;
- 2. PT returned to normal after vitamin K treatment;
- 3. Vitamin K deficiency-inducing protein (PIVKA-II.) levels are above the normal range.
Diagnosis of suspicious VKDB: PT and APTT were abnormal compared to control values of the same age and met one of the 3 additional criteria above.
Simplified diagnostic criteria (UK): spontaneous bruising, hemorrhage, or intracerebral haemorrhage with normal or elevated platelet count and prolonged PT (at least 2 times the norm) in infants aged 6 months, and exclusion of hereditary coagulopathy or DIC.
Among the indicators, PIVKA-II is more sensitive, which can reflect the subclinical status of vitamin K deficiency before the abnormal coagulation index. According to the survey, the positive rate of PIVKA-II in infants in mainland China is > 40%, indicating that there are many infants with subclinical vitamin K deficiency. Infants with PIVKA-II-positive and prolonged PT without bleeding symptoms should be concerned because they can induce blood under the influence of infection, diarrhea, and hepatobiliary disease.
treat
Patients who have bleeding should be injected with vitamin K1 1~2mg intramuscularly immediately, and the bleeding will be reduced within a few hours, and it will be completely stopped within 24 hours. Patients with hemorrhagic shock should be immediately transfused with fresh frozen plasma of 10~20ml/kg, and prothrombin complex should be used to improve coagulation function.
Children with suspected VKDB can be given vitamin K1 while waiting for test results, which has a rapid onset of action and a high safety profile.
prophylaxis
At present, there is no uniformity at home and abroad, and the following is the recommended scheme of the 9th edition of Pediatrics.
Mother
Drugs that affect vitamin K metabolism during pregnancy, such as warfarin, anticonvulsants, rifampicin, isoniazid, etc., should be injected intramuscularly 10 mg of vitamin K1 once in the last 3 months of pregnancy and before delivery.
For exclusively breastfeeding mothers, vitamin K1 is 20 mg orally twice a week.
newborn
All newborns are intramuscularly injected with vitamin K1 0.5~1mg once immediately after birth, and premature infants are given for 3 days.
High-risk children
Premature infants, high-risk infants with hepatobiliary diseases (cholestasis, hepatitis syndrome, etc.), chronic diarrhea, long-term antibiotic use, long-term total intravenous nutrition, etc., should be injected with vitamin K1 0.5~1mg once a week.
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