[Editor's note: The following are excerpts from a lengthy article published
in Midwifery Today magazine. For fuller understanding of this complex topic,
we recommend you read the article, which lists 40 references, in its entirety.
This issue also contains two other excellent, referenced articles about vitamin
The recommended daily intake (RDI) of vitamin K is 10 mcg for infants. Human
milk does not provide this much vitamin K to the breastfed baby at any stage of
lactation, despite the fact that mothers on average consumed 670% of the adult
RDI. In fact, nursing babies received on average only 7-13% of the RDI. Giving
the mothers a modest daily supplement of 88 mcg/day did not increase breastmilk
concentration of the vitamin. A large daily supplement, 5000 mcg, taken by breastfeeding
mothers increased the amount of vitamin K in their milk to the same level with
which formulas are fortified.
Whether or not the RDI represents the amount of vitamin K that babies truly
need is a matter that can be debated. The small quantities of vitamin K in human
milk are adequate for most babies, as evidenced by the fact that the vast majority
of breastfed babies do not develop vitamin K deficiency bleeding (VKDB).
A single IM dose results in extremely high levels of vitamin K in the newborns'
blood soon after injection: the peak median plasma concentration at 12 hours is
9000 times the normal adult level, and from one to four days after the injection the levels are about 100 times higher than in a normal adult. It is unknown what
risk there is in exposing the newborn to these high concentrations of vitamin
K. Cancer was suggested as a potential risk as early as 1983, but the evidence
to date is inconclusive.
Golding et al. found that intramuscular vitamin K supplementation given to newborns
was associated with an increased risk of certain childhood cancers (B J Cancer
62: 304-308). This unexpected result occurred in a national cohort study done
in Britain. The authors found similar results in a second study. Several subsequent
studies showed no evidence of risk. However, the most recent studies have been
unable to exclude the possibility that intramuscular vitamin K given to newborns
may raise their risk for developing acute lymphoblastic leukemia in childhood.
The evidence does not prove that intramuscular vitamin K is carcinogenic, and
the risk, if any, is likely to be low. The evidence does not suggest that oral
vitamin K poses a risk.
Some opponents of vitamin K supplementation argue that evolution designed human
milk to contain the optimal amount of vitamin K for the nursing baby. This may
well be true, but it is possible that a design that worked well for lactating
women during the majority of human evolution would not work as well in the contemporary
world. The majority of human evolution occurred during the long period before
agriculture, when humans were hunter-gatherers. The diets of humans during those
times were likely very different than diets today, and this could have affected
the level of vitamin K present in mothers' milk.
Intramuscular vitamin K prevents late VKDB in almost all babies. Although late
VKDB does sometimes occur after a single oral dose, and to a lesser extent after
a series of three doses, these oral dosing regimens do confer some degree of protection.
A recent study, using data from Britain, estimates that among breastfed babies
not given vitamin K, the risk of late VKDB is 19.1 per 100,000, or almost one
in 5000. This risk can be considered low because the vast majority of babies will
not develop the disease. A midwife could practice many years and never see a single
- Provide parents with information during pregnancy so they can make an informed
decision about whether or not they want vitamin K prophylaxis and if so, which
type (IM or oral).
- The baby's healthcare provider should be made aware of whether or not the
baby received vitamin K, and, if so, in what form. Knowing the baby did not receive
prophylaxis can improve the chances of early diagnosis and treatment in the rare
event of VKDB.
- For parents who decide not to give vitamin K, give a handout explaining the
symptoms of VKDB and advise them to obtain immediate care for a baby who develops
- If jaundice is present after two weeks, bilirubin should be evaluated to see
which type of jaundice is present. Conjugated hyperbilirubinemia may indicate
cholestasis, which puts a baby at higher risk of developing VKDB.
- Jennifer Enock, "Babies and Vitamin K," Midwifery Today Issue 56, Winter 2000
I suggest it is extremely unlikely that the relationship between vitamin K levels
and hemorrhagic disease of the newborn (HDN) is a simple one. I can think of several
birth-related factors that might affect this issue. For instance, we should ask
a woman what happened during the third stage of her labor. Was the cord cut quickly,
or was the baby allowed as much time as she needed to regulate the amount of clotting
factors and other relevant components in the baby's blood? What impact does the
woman's diet during pregnancy have on the situation? And what are the possible
reasons that nature intended babies to have low levels of vitamin K?
I worked in a community midwifery practice at a time when the decision was made
to increase from one to three doses of the (oral) vitamin K given to breastfed
babies. The first dose was given at birth and the second on the seventh day postpartum.
While we would generally stop seeing women on the tenth day postpartum, the other
midwives and I noticed that almost as soon as this new policy became practice,
we suddenly had moderate numbers of women who were not discharged from midwifery
care until the twelfth or thirteenth day. Analysis of the records showed that
the majority of these women had babies who were becoming jaundiced on the eighth
or ninth day following their second dose of vitamin K. Another midwife has suggested
that perhaps babies cannot handle the increased prothrombin that comes about as
a result of receiving vitamin K. Perhaps this would explain why babies are born
with their relatively low levels.
Von Kries (BMJ 316:161-62) summarizes some of the recent history of vitamin
K, which in some areas was not given until the early 1980s because late-onset
HDN had not been a problem until then. This in itself should raise concerns. If
all babies were pathologically deficient in vitamin K, surely someone would have
noticed in these areas sometime before the 1980s. How does the increase (in some
areas) of late-onset HDN relate to the changes in the practices women experience
during childbirth? Did the "need" for routine vitamin K increase alongside
increasing medicalization of birth?
- Sara Wickham, "Vitamin K: A Flaw in the Blueprint?", Midwifery Today Issue 56
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Question of the Week
Q: Has anyone developed her own system for newborn
gestational age assessment? The New Ballard Scale seems more elaborate to me than
is necessary for term babies who are born at home. I know that experienced midwives
can quickly look over a baby and estimate the gestational age, but for now I would like to find a concise format to document characteristics for EGA.
- Amy Kieffer, student midwife
Send your responses to:
Question of the Week Responses
Q: As a care provider for women during their childbearing
years, it is also essential to be able to have competent information I can give
to the women who I continue to care for beyond the birthing times of their lives.
What are the signs and symptoms of breast cancer and what is the percentage of
women who breastfeed to those who don't correlate with cancerous tumors in women's
breasts? Can you recommend any books that are informative, honest and coming from
a natural healing perspective?
- Amanda Moore, midwifery student
A: Your question is timely as I am preparing a curriculum about breast
health. I would strongly recommend Susun Weed's Breast Health: The Wise Woman
Way. She describes many different approaches to maintaining healthy breasts,
as well as prevention and treatment of cancer. Dr. Susan Love's Breast Book
and Christiane Northrup's Women's Bodies, Women's Wisdom are also essential
resources. Susan Love's text is a wonderful reference text on the female breast,
breast care and screening, diagnosis, treatment and research. Chapter 10 of WBWW
is excellent, and finally Natalie Angier's Woman: An Intimate Geography
explores the cultural context of breasts, their care and function in chapters
7 (Circular Reasoning, the Story of the Breast) and 8 (Holy Water: Breast Milk).
There are also extensive resources on the web including access to medical, midwifery
and nursing journals through a number of sites.
- Anne Maranta, RM
A: Read Breast Cancer? Breast Health! By Susun Weed. It is the
best book I have read about breast cancer risks and prevention. It is wonderful.
A:Breast Cancer, Breast Health by Susan Weed is an excellent book
not only for breast health concerns but for anyone about to undergo any type of
surgery. Highly recommended by everyone I have offered it to.
Know a strong woman? Helping empower one? If you haven't already done so, please
forward this issue of Midwifery Today E-News to one or two of your friends or
business associates. Thanks so much!
In regard to Samantha McCormick's statement about BTL (Bilateral Tubal Ligation)
and early menopause [Issue 3:42]: I will take you up on finding or creating the
research on BTL. For a few years I have questioned why some people so adamantly
accept that women do go through some changes after having BTL. I know that it's
going to take a fairly long time to acquire the information because even though
it is out there, it's not published.
In addition, anyone interested in supplying information either from clients,
friends, family or self in regard to changes or effects after a BTL, your input
will be more than welcome. I'm going to get started on a questionnaire/survey
so I would also appreciate questions to help make it a complete one.
I have always thought that women went through an array of changes after BTL
and have always asked "professionals" about it--only to end up with
the same type of response that Ms. McCormick stated. Yet, when I go to the source,
the women, many of them have something to say to contradict the "professionals".
But they keep quiet and move on because they have no one to back them up. Let's
change that and provide them with peace of mind knowing that what they are feeling
and experiencing is not unique to them and may be a "medical response"
- Margie Bou
Re: psychological or physiological reasons for a fast labor [Issue 3:43]: I
am only speaking from my personal belief and experience. My sister-in-law's due
date was 10 days before mine. I am a very relaxed person; she's uptight. Right
away, she was told she had high blood pressure. Throughout our pregnancies, I
exercised, meditated, ate right, and journaled about my pregnancy and what I thought
motherhood would be like. She did not. I took hypnobirthing as my only childbirth
education class--I couldn't be worried with the "what ifs" of labor
and delivery; I was more concerned with facing any hidden fears I may have had
about birth (which really only turned out to be other people's fears that landed
on me). She was too concerned with the "what ifs" and attended all her
hospital CBE classes faithfully. When it came time for each of us to bring our
babies into the world, she was induced due to preeclampsia. She entered the hospital
fearful of "pain" and made her fears come true. She did deliver vaginally,
but it was after 27 hours of labor, cervidix, Pitocin, Nubaine, a sliced membrane
sack, epidural, two episiotomies, a pretty good natural tear, fetal distress,
a vacuum extraction, three doctors, seven nurses, much screaming and four days
of hospital recovery (which is pretty unusual for our local hospitals unless a
woman has had a cesarean birth).
I, on the other hand, experienced an easy and beautiful waterbirth with a four-hour
labor. In fact, I didn't know I was in labor until my midwife told me. I felt
no fear, but joy to an extent I had never felt before. My baby descended on her
own until she was just about to be born. And when I decided to push, I did so
through three surges, and on the last one, she crowned and continued to slide
right out of me into the warm water so fast I didn't even realize it was over.
I did tear a little because she had a 14-inch head, but that was the extent of
my "birthing trauma." I knew as soon as it was over I would do it again.
I am a firm believer in the power of the mind, and I have very little rebutting
this belief from the experience I've faced. You cannot control birth, but you
can make a great impact on how it will be from your thoughts and feelings.
I recently suffered from obstetric cholestasis and just wish to let you know
about my experience. At 35 weeks I had intense, unbearable itching all night long
(everywhere, including soles of feet) and to a lesser degree during the day. At
36 weeks a blood test showed a bile acid level of 16. By the time of the blood
test I'd started a rapid cleanse diet--just water for a day, then fresh vegetable
juices for two days, then fresh fruit and vegetables. Within five days, all itching
vanished. The hospital told me there was no point in having another bile-acid
test (to see if it had returned to normal) because once cholestasis is diagnosed,
the diagnosis does not change. I do not know if the measures I used were any use
in combating cholestasis but in my case it certainly relieved (and totally got
rid of) any itching.
- Anni Taylor
I am a qualified midwife in England about to embark on my degree dissertation.
I want to look at the appropriateness of pethidine (pamergan, demerol, meperidine)
as a pain relief in labour. In addition to looking at "official" studies
and RCTs, I want to know the experiences of women and birth attendants with this
drug. If anyone has any experiences, feelings or stories good or bad, I would
love to hear them. In particular I am interested in how well it did or did not
relieve pain, the emotional impact, and any impact on breastfeeding.
- Sarah Carter
I recently read an article on the Internet stating that women may have more
problems with pinworms than men because the pinworms can go into the vulva, uterus
and the fallopian tubes. Is this possible in a pregnant woman? My OB knows nothing;
neither do the midwives in my area.
Has anyone heard of the link between zinc deficiency and long gestation, two
to three weeks overdue?
- Francie Smith
Regarding the doula whose client has a bicornate uterus: I had a student with this condition who went on to birth vaginally, full term, after a 67-hour labor. The biggest risk as I understood it was that of third trimester stillbirth/miscarriage, followed by breech. Prolonged or prodromal labor apparently is common. I found the most helpful information in Anne Frye's books Holistic Midwifery and Understanding Diagnostic Tests in the Childbearing Year. You might want to make sure her nutrition and emotional support are excellent. It stands to reason that a strong, healthy, well-nourished woman can grow a strong healthy baby, better built to withstand any problems occurring from structural abnormalities. Check out Dr. Brewer's website at www.blueribbonbaby.com
- Amy V. Haas, BCCE
EDITOR'S NOTE: Only letters sent to the E-News official email address,
will be considered for inclusion. Letters sent to ANY OTHER email addresses will
not be considered.
Midwifery Today Issue 61: Postpartum
The Spring issue of Midwifery Today magazine will focus on postpartum
issues and situations. If you have a clinical article, personal experience piece
or something educational regarding this period after childbirth, please submit
it to email@example.com.
Deadline is December 1, 2001. We look forward to seeing your stories!
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