Neonatal Vitamin K Refusal Linked to Immunization Refusal ‏

Laurie Barclay, MD

August 18, 2014

Refusal of neonatal vitamin K is uncommon and is linked to midwife delivery at home or in a birth center and refusal of immunization, according to a retrospective, population-based cohort study published in the September issue of Pediatrics.

"Neonatal Vitamin K prophylaxis is an effective intervention for reducing vitamin K deficiency bleeding," write Vanita Sahni, MHSc, from Alberta Health Surveillance and Assessment in Edmonton, Canada, and colleagues. "A recently published report of parental refusal of vitamin K prompted an investigation of the prevalence and characteristics of this group, and exploration of whether these same parents were likely to subsequently refuse immunization for their children."

Vitamin K deficiency bleeding into the brain may cause long-term brain damage and death. The Centers for Disease Control and Prevention identified 4 cases of vitamin K deficiency bleeding in infants in Tennessee in 2013; in each case, the child failed to receive neonatal vitamin K because of parental refusal.

Using linked administrative health data, Sahni and colleagues examined a population-based cohort of all infants born in Alberta between 2006 and 2012.

Of the 282,378 infants in the cohort, 99.7% received vitamin K, and 0.3% did not because of parental refusal. Although the rate was low overall, the investigators found a small but significant increase in the rate of refusal during the study period, from 0.21% refusing vitamin K in 2006 to 0.39% in 2012 (P < .001).

Women who had midwife-assisted deliveries were 8 times more likely to be refused vitamin K compared with women who had physician-attended delivery (risk ratio, 8.4; 95% confidence interval [CI], 6.5 - 11.0).

Similarly, those women with a planned home delivery were nearly 5 times more likely to decline vitamin K than were those who had a planned hospital delivery (risk ratio, 4.9; 95% CI, 3.8 - 6.4), and those who planned delivery in a birth center was more than 3 times as likely to refuse vitamin K (risk ratio, 3.6; 95% CI, 2.3 - 5.6).

Moreover, the researchers found that the relative risk of having no recommended childhood vaccines at age 15 months was nearly 15 times greater (14.6; 95% CI, 13.9 - 15.3) among children of parents who declined neonatal vitamin K than in children of parents who accepted the intervention.

"This is the first population-based study to characterize parents who are likely to decline vitamin K for their infants and whose children are likely to be unimmunized," the study authors write. "These findings enable earlier identification of high-risk parents and provide an opportunity to enact strategies to increase uptake of vitamin K and childhood immunizations."

Limitations of this study include its potential for bias, as data on vitamin K prophylaxis were unavailable on 19% of live births; possible lack of generalizability to regions in which midwifery care is the standard of care; and inability to distinguish between parental choice and other barriers preventing uptake of immunization.

"These findings [highlight] the need for physicians to provide anticipatory guidance on the benefits of vitamin K to parents who are planning home birth or a midwife-attended delivery [and point] to an opportunity to engage midwives so that education about the risks and benefits of vitamin K prophylaxis can begin before birth among a population group that is likely to decline prophylaxis," the authors conclude.

The senior author was supported by a fellowship from the Canadian Institutes of Health Research and a postdoctoral clinician fellowship from Alberta Innovates-Health Solutions. The other authors have disclosed no relevant financial relationships.

Pediatrics. 2014;134:497-503.

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