#453 - [Neo News] - 📌 Are You Still Assuming Every Newborn Got Vitamin K?

Vitamin K refusal has crossed 5%. That's one in twenty babies, and the curve is bending the wrong way. Ben and Eli work through a new Pediatrics case review that opens with a warning shot, that hemorrhagic presentation in an infant should no longer be a diagnostic mystery, alongside a JAMA letter tracking refusal from 2.9% in 2017 to 5.2% in 2024. Eighty-one times the risk. Intracranial hemorrhage in most late-onset cases. Twenty percent mortality. They talk about the halo effect on other refusals, the ICD code you should be using, and why this conversation belongs in the obstetrics office, not the nursery.

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Vitamin K Deficiency Bleeding After Refusal: A Sentinel Event in a Misinformation Era. Jacobs JW, Booth GS, Wheeler AP, Adkins BD.Pediatrics. 2026 May 1;157(5):e2026075994. doi: 10.1542/peds.2026-075994.PMID: 41916583 No abstract available.

Trends in Vitamin K Administration Among Infants. Scott K, Miller E, Culhane JF, Greenspan J, Handley SC, Lo JY, Knake LA, McKenney KM, Burris HH, Dysart K.JAMA. 2026 Jan 20;335(3):272-274. doi: 10.1001/jama.2025.21460.PMID: 41359326 Free PMC article.

Babies Are Bleeding to Death as Parents Reject a Vitamin Shot Given at Birth
https://www.propublica.org/article/more-parents-decline-vitamin-k-shot-newborns

Transcript

Eli Cahan (00:01.955)
Hello everybody, and welcome back to Neo News. This is our segment devoted to promoting the doctor patient relationship by keeping you up to date with what's buzzing in the news today. We're going to move on to our next article, and we're going to talk about something that we never talk about on this show, just kidding: vitamin K. A couple of really interesting articles have come out recently on vitamin K and the way in which vitamin K is finding itself, perhaps, in the crossfire

of culture wars. And Ben, this article that you picked was a really interesting kind of article in Pediatrics that was one dose case review, one dose op-ed, and one dose medical mystery. The article describes the case of hemorrhagic consequences, coagulopathy associated with

vitamin K. And after the case presentation, the first line in the next paragraph in this article reads: this presentation of hemorrhagic symptoms should not be a diagnostic mystery, which I find to be quite a striking line. This presentation should not be a diagnostic mystery, because it's basically saying we're in a world now where this needs to always be on your differential.

The article goes on to describe some of the statistics about the difference in risk of hemorrhagic consequences with and without vitamin K. And it says that without vitamin K, the risk of this syndrome occurs in approximately one in 14,000 to one in 25,000 infants. With intramuscular vitamin K prophylaxis, the incidence falls to less than one in 100,000.

They also cite statistics showing that infants who do not receive IM vitamin K are estimated to be about 81 times more likely to develop late-onset coagulopathy. And they go on to describe the place of vitamin K in broader decisions that patients may be making. They say patients who decline intramuscular vitamin K are not making an isolated choice about one intervention.

Eli Cahan (02:23.531)
Refusal often co-occurs with refusal of other newborn preventive services, including ocular prophylaxis and the hepatitis B vaccine. The American Academy of Pediatrics has noted that parental objections to vitamin K generally fall into three broad categories: belief systems, infant welfare concerns, and outside influencing factors. And those outside influences can include friends, celebrities, and healthcare professionals.

Ben Courchia (02:50.028)
And social media should have been on there.

Eli Cahan (02:52.121)
And social media. Maybe celebrities are on social media, but you can define that anyway. The article also cites a recent JAMA study showing that the proportion of infants not receiving IM vitamin K increased from about 2.9% in 2017 to 5.2% in 2024. Exemplary of a bit of a sea change in how people are thinking about immediate postnatal care,

Ben Courchia (02:55.5)
Maybe.

Eli Cahan (03:20.635)
including the first two interventions that hopefully any healthy baby would get. Ben, what do you make of the trend in the data around vitamin K? What do you make of this really interesting article, and what do you make of the broader conversation around vitamin K?

Ben Courchia (03:36.291)
Yeah, thank you, Eli. I think it's a very interesting topic. I think that it's important for us to be up to date on what the data actually shows. So I want to re-emphasize one number that you quoted. The relative risk, obviously, that infants who do not receive intramuscular vitamin K are estimated to be 81 times more likely to develop late-onset vitamin K deficiency compared to those who do. I think that this is a very important statistic for

us clinicians to relay to families. And in terms of when bleeding does occur, so let's say there is some vitamin K deficiency bleeding, then what we really worry about, specifically in the first six months of life, is intracranial hemorrhage. And intracranial hemorrhage occurs in 30 to 60% of late-onset cases, with a mortality rate that can be as high as 20%,

and 40% who suffer long-term neurological injury. So the expected consequences of a stroke, basically. And so I think that these numbers should be memorized. Again, 81 times more likely to develop late-onset bleeding. If you have late-onset bleeding, you have a 30 to 60% chance of having an intracranial bleed. If you have an intracranial bleed, you have a 20% chance of dying, a 40% chance of having long-term

neurological sequelae. All of this could be prevented with one single shot at birth, which to me is staggering. What's very interesting about what you described, the fact that decisions are made in conjunction with other decisions, I think is an interesting one, because this mistrust in the system also sometimes has a halo effect and leads to mistrust, for example, in formula usage. So very often, parents who will refuse

vitamin K will also be parents who will say, we just want to exclusively breastfeed our baby. We're not going to give any formula because formulas contain all these nasty things. And that's one point where, actually, no problem, right? If you want to exclusively breastfeed your baby and you're going to do it well and you're going to provide enough nutrition, then that's great. That's actually a very good decision. But where we often forget is that the fact that you're exclusively breastfeeding is actually a risk factor for

Ben Courchia (06:02.22)
developing vitamin K deficiency bleeding. And so it is an interesting scenario in which you're making a bunch of decisions together, sometimes driven by the same motivation. One of them is actually not quite good, about exclusively breastfeeding a baby, but also having a direct amplification factor on your second decision of not giving vitamin K. And I think that this is something that to me is interesting from a decision theory standpoint, where

really, that's increasing the risk of seeing negative outcomes. What I think is also interesting is that you mentioned the trend, right? You mentioned the increase from about 2.9 to 5.2% in the span of what, seven years. I kind of agree with some of the discussion points on this subject that it's probably an underestimate.

Again, the sampling bias of these studies obviously is that you're capturing a lot of hospital births, but it's not clear that this is actually well representative of the current true incidence of refusal of vitamin K. And I am very eager to see the follow-up to this study, because I suspect that there's going to be an inflection point where we're going to find out that it's going to

grow exponentially. I don't know about your experiences as a fellow, but at least for me, covering the nursery, it is routine for us to see patients refusing vitamin K supplementation and injection. And to that point, I also want to mention for all the clinicians out there that when you are seeing patients in the nursery or in the labor and delivery suite, when you are documenting on these patients, there is an ICD code for refusal of vitamin K. And I think that

it's a nice thing to put in the problem list, because it's obviously something that, as these papers mention, you want to potentially leave that thread in for outpatient follow-up and for other people to also keep track of this. Because like you said in the beginning, it should not be a diagnostic mystery. But yeah, it's hard, because we've been trained under the assumption that everybody got vitamin K, and now it's going to be, I have to remember that I have to tease

Ben Courchia (08:27.415)
my patients apart, between the ones who did receive it versus the ones who did not receive it. And sometimes it's hard if it's just one sentence in a long discharge summary. But that's why I like this problem list idea, where it's actually on the problem list and you'll remember that and obviously be more aware of it, and make the pediatrician aware of that as well. So these are my thoughts on this subject.

Eli Cahan (08:51.917)
Yeah, spoken like a true medical director. It's interesting. When I've seen infants in the follow-up clinic, it's one of those things that if the baby isn't born at your hospital and you have all this challenge getting the baby's records, and maybe it's not on Care Everywhere. If you're on Epic, and even on Care Everywhere, sometimes it's almost impossible to divine where the medications are.

Ben Courchia (08:54.767)
[laughs]

Eli Cahan (09:20.341)
It's one of those that I feel like I am guilty of, that if I don't see for or against, I assume they got it. And I think if you have no other takeaway from this conversation, I think we need to question that assumption, right? It's kind of like if you're thinking about Haemophilus influenzae in parts of the country where vaccine rates are lower, we just have to keep this on our differential.

And I want to highlight, there was an amazing story on this that just makes plain what denials of vitamin K look like, in ProPublica by Duaa Eldeib, who is a dear friend and wonderful mentor and colleague to me. Duaa wrote about a series of infants who arrived healthy, passed their newborn screens, and in some cases made it to their two-week visits without concern.

Ben Courchia (09:46.639)
Mm-hmm.

Eli Cahan (10:15.703)
And then, without warning, their systems began to shut down. Sudden seizures in a seven-week-old boy in Maryland. Apnea in an infant girl in Alabama. Vomiting and lethargy in a baby boy in Kentucky. Bleeding around the umbilicus in a Texas newborn not yet two weeks old. These are all cases of vitamin K refusal. And I think the article does a really nice job synthesizing

the conversation in the Pediatrics article, as well as in the JAMA research letter, all of which is to say these conversations have high stakes. It is not the kind of thing where, if the family does refuse on day of life one, we can say, well, as long as that kid looks okay by day of life three, when mom is going to get discharged, then we're out of the woods. Late-onset coagulopathy is a real thing. There are babies

who are dying or suffering very severe morbidity from it. And it is all of our prerogative in the NICU to start having these conversations, and in the newborn nursery to start having those conversations, including that even if the family doesn't get the shot with us, there still may be an opportunity for them to get it at their early discharge clinic or at their next visit. And I think, as the gateways into this system for new families as well as expanding families, this is

unfortunately a trend that we're going to have to pay more attention to diagnostically, and hopefully something that, using communication as an intervention, as we've talked about previously on the podcast, may be a good opportunity for us to own that responsibility.

Ben Courchia (12:00.803)
Yeah. And I think it highlights the fact that this is really going to force us as a field to move from a checklist approach, where you say got it, didn't get it, to really having a structured conversation, starting with the obstetricians, where we're going to have to start having discussions and counseling about this very early on, so that it's not something that we address after the baby is born, when the parents have made up their mind. It's a bit more of a structured approach to counseling,

with very clear handoffs between teams, where obstetricians can sign this out, just like they're signing out the gestational age. We can have conversations about that and we can sign this out to the outpatient world as well. So let's see where this takes us. The 5% threshold has been crossed and the graph is not pretty. We'll post that on social media, but yeah.

Eli Cahan (12:50.701)
Yeah. By the way, you know what 5% means? One in 20, right? How many babies are in the nursery? We have 40 babies in our NICU. We have 30 in our step down. We've got lots in the nursery. That's like one per early discharge clinic, at least.

Ben Courchia (12:54.799)
[laughs]

Ben Courchia (13:07.727)
Yeah, that's what I was saying earlier. When you say one in 20 for our nursery, that kind of means maybe one every other day, if you were to do like 10 patients a day. But I feel like I see multiples every day. I think this data stopping in 2024 is going to be staggering when we start accruing 25, 26, and eventually 27, because it feels like it's way more.

Eli Cahan (13:35.885)
Yeah, it definitely has not gotten better since 2024. Last thing I'll say, Ben. I love that you commented on the opportunity to start these conversations early. I have a habit now in my prenatal consults of talking about vaccines, especially for these micropreemies. When we're talking about the pulmonary consequences of prematurity, often I find myself talking about the importance of vaccination, both of that child when they're at an appropriate age and appropriate weight, but also of the family. And vitamin K may

Ben Courchia (13:37.751)
No, no.

Ben Courchia (13:53.593)
Yeah.

Eli Cahan (14:03.575)
I think it's a great idea that maybe this is something we should add to our list of things that we're talking about in the immediate postnatal period.

Ben Courchia (14:07.883)
Yeah. And then unfortunately, the patients that we get tend to get their vitamin K. I feel like the rates of refusal in the NICU are probably lower than they are in the well-baby nursery. So I think it really is going to be incumbent on the obstetrics world, but we'll see. Why not? They're excellent. So there's no reason why they couldn't get that.

Eli Cahan (14:27.447)
Well, we'll keep a pulse on this. Thanks, Ben.

Ben Courchia (14:27.567)
All right, Eli. I'll see you next time.

Bye.