Vitamin K Deficiency Bleeding: Symptoms, Types, Causes and Treatment

Vitamin K plays a critical role in blood clotting, and its deficiency can lead to a potentially life-threatening condition known as vitamin K deficiency bleeding (VKDB). This disorder, particularly common in newborns and infants, can cause a range of bleeding complications, from mild bruising to catastrophic intracranial hemorrhages. Understanding the symptoms, the different types of VKDB, its causes, and the best treatment strategies is essential for parents, caregivers, and healthcare professionals alike. This comprehensive article synthesizes evidence from recent research to provide an up-to-date overview of VKDB and how it can be managed and, most importantly, prevented.

Symptoms of Vitamin K Deficiency Bleeding

Vitamin K deficiency bleeding can manifest in various ways, from subtle warning signs to sudden, severe hemorrhages. Recognizing these symptoms early can be the difference between timely intervention and serious complications.

Symptom	Description/Example	Typical Age of Onset	Sources
Bleeding/Ecchymosis	Bruising, skin or mucosal bleeding	Any (often <6 months)	3 5 8
Intracranial Hemorrhage	Bleeding inside the skull (can be fatal)	2-24 weeks (late VKDB)	3 4 5 6 8
Gastrointestinal Bleeding	Vomiting blood, blood in stool	1-7 days (classic); up to 6 months	5 12
Poor Feeding/Vomiting	Feeding intolerance, frequent vomiting	2-24 weeks (late VKDB)	2 3 4
Jaundice	Yellowing of skin and eyes	Any	3 9
Pallor	Unusual paleness	Any	3
Lethargy/Irritability	Decreased activity, irritability	Any	2 3 4
Convulsions	Seizures, bulging fontanelles	2-24 weeks (late VKDB)	3 4

Table 1: Key Symptoms of Vitamin K Deficiency Bleeding

Recognizing VKDB: More Than Just Bleeding

VKDB is notorious for its wide spectrum of presentations. While some infants may only show minor bruising or bleeding from the nose or circumcision site, others may suddenly collapse with life-threatening brain bleeds.

• Skin and Mucosal Bleeding: This can appear as unexplained bruises, blood in the urine or stool, nosebleeds, or oozing from puncture sites (such as after a blood test or circumcision) 3 5 8 12.
• Intracranial Hemorrhage: The most severe form—especially in late VKDB—often presents with neurological symptoms. These may include seizures (convulsions), a bulging fontanelle (the soft spot on an infant's head), lethargy, irritability, or even coma. About 73% of late VKDB cases involve brain bleeds, and mortality rates can reach 30% or higher 3 4 6.
• Gastrointestinal Bleeding: Blood in vomit or stool is a classic sign, particularly in the first week of life (classic VKDB), but can also occur later 5 12.
• Non-Specific Symptoms: Infants may exhibit poor feeding, vomiting, pallor, or jaundice. These can be subtle and easily mistaken for other infant illnesses, which is why high suspicion is needed, especially in at-risk populations 2 3 4 9.

Why Symptoms Vary

• Timing: The type of VKDB (early, classic, late) affects which symptoms are likely to appear and when.
• Bleed Location: Symptoms depend on where the bleeding happens—brain bleeds cause neurological symptoms, while GI bleeds result in blood-stained vomit or stool.
• Severity: Some infants have only mild symptoms, while others deteriorate rapidly.

Types of Vitamin K Deficiency Bleeding

Not all VKDB is the same. Understanding the different types helps guide vigilance, prevention, and treatment.

Type	Onset/Age Range	Common Symptoms/Features	Sources
Early	Within first 24 hours	Severe, often internal bleeding; rare	1 8 12
Classic	Day 1 – 7 after birth	GI, skin, nasal, circumcision bleeding	1 8 12 13
Late	2 weeks – 6 months (peaks 3–8 weeks)	Mainly intracranial hemorrhage, also skin/GI	1 3 4 5 6 8 12 13
Primary	Any type, but breast milk as only risk factor	No underlying disease	5
Secondary	Any type, but with additional risk factor (e.g., liver disease, malabsorption)	Underlying illness present	5 9 10

Table 2: Types of Vitamin K Deficiency Bleeding

Early VKDB

• Timing: Within 24 hours of birth 1 8 12.
• Causes: Usually due to maternal medications that interfere with vitamin K (like anticonvulsants or antibiotics).
• Features: Severe, often internal bleeding, but very rare.

Classic VKDB

• Timing: First week of life (day 1–7) 1 8 12 13.
• Features: Presents with bleeding from the GI tract, umbilical stump, skin, nose, or after circumcision.
• Risk Factors: Delayed or inadequate feeding, no vitamin K at birth.

Late VKDB

• Timing: Between 2 weeks and 6 months, peaking at 3–8 weeks 1 3 4 5 6 8 13.
• Features: Most dangerous; up to 73–97% present with intracranial hemorrhage 3 4 6.
• Risk Factors: Almost always occurs in exclusively breastfed infants, often with unrecognized liver or gut disease (e.g., cholestasis, biliary atresia) 1 5 9.
• Outcomes: High risk of death or lasting neurological damage.

Primary vs. Secondary VKDB

• Primary VKDB: Occurs in infants who are otherwise healthy except for breastfeeding as the only risk factor 5.
• Secondary VKDB: Occurs in infants with additional causes that impair vitamin K absorption or utilization, such as liver disease, chronic diarrhea, or use of certain medications (e.g., antibiotics) 5 9 10.

Causes of Vitamin K Deficiency Bleeding

Why do some infants, and rarely older children or adults, develop VKDB? The causes are a mix of physiological factors, feeding practices, underlying illnesses, and, occasionally, genetic conditions.

Cause	Description/Mechanism	Predominant VKDB Type	Sources
Low Vitamin K at Birth	Poor placental transfer, immature gut flora	All	1 8 16
Breastfeeding	Low vitamin K in breast milk	Late	1 4 5 8 13
Malabsorption Disorders	Cholestasis, biliary atresia, chronic diarrhea	Late (secondary)	1 5 9 15
No Prophylaxis at Birth	Omission/refusal of vitamin K shot	Classic, Late	2 13 14
Maternal Medications	Anticonvulsants, antibiotics, anti-tuberculous drugs (inhibit vitamin K function)	Early	1 8 12
Antibiotic Use	Disruption of gut bacteria that make vitamin K	Secondary	3 10
Hereditary Deficiency	Genetic defects in vitamin K metabolism	Rare, any age	7
Prematurity/Low Birth Weight	Delayed feeding, immature liver/gut	All	4 16

Table 3: Causes of Vitamin K Deficiency Bleeding

Why Infants Are Vulnerable

• Low Vitamin K Stores: Babies are born with very little vitamin K because it doesn't cross the placenta well, and their gut flora (which helps produce vitamin K) is undeveloped 1 8 16.
• Breastfeeding: While breast milk is ideal in many ways, it has much less vitamin K than formula, putting exclusively breastfed infants at higher risk—especially if they received no vitamin K prophylaxis 1 4 5 8 13.
• Delayed or Inadequate Feeding: Infrequent or poor feeding in the first days of life increases the risk of VKDB, particularly the classic form 1.

Medical Conditions: The Secondary Causes

• Cholestasis/Biliary Atresia: These conditions block the flow of bile, which is needed to absorb fat-soluble vitamins like K. Babies with undetected liver disease are at especially high risk for late VKDB, even if they receive oral prophylaxis 1 5 9 15.
• Chronic Diarrhea/Malabsorption: Any disease that impairs fat absorption increases the risk 5 9.
• Antibiotic Use: Prolonged antibiotics can kill gut bacteria that produce vitamin K, leading to deficiency, particularly in children and adults with underlying issues 3 10.

Iatrogenic and Hereditary Causes

• Maternal Medications: Drugs like anticonvulsants (phenytoin, carbamazepine), antituberculous agents, and some antibiotics taken by the mother can interfere with vitamin K in the fetus, leading to early VKDB 1 8 12.
• Hereditary Disorders: Rare genetic conditions can cause combined deficiency of vitamin K-dependent clotting factors, leading to chronic bleeding disorders in infants and children 7.

Missed Prophylaxis: A Preventable Cause

• No Vitamin K at Birth: Refusal or omission of vitamin K prophylaxis at birth remains a major risk factor for both classic and late VKDB, especially in high-income settings where most other causes are rare 2 13 14.

Treatment of Vitamin K Deficiency Bleeding

VKDB is a preventable and treatable condition—if recognized and managed quickly. Treatment focuses on stopping bleeding, correcting deficiency, and preventing recurrence.

Treatment	Application/Indication	Effectiveness/Outcome	Sources
Vitamin K Injection (IM/IV)	Given at birth for prevention; IV/IM for active bleeding	Rapid correction of coagulation, bleeding stops within hours	1 2 3 6 8 12 13
Oral Vitamin K	Preventive use, especially where IM not feasible	Less effective for high-risk infants, requires multiple dosing	1 8 13 15
Plasma/Blood Products	Severe bleeding or before surgery	Provides clotting factors directly	7
Surgery	Needed for severe intracranial hemorrhage	May be life-saving but carries risks	2 3 6
Monitoring/Supportive Care	Observation, treating underlying cause	Prevents recurrence/complications	1 5 9

Table 4: Treatment Approaches for VKDB

Prevention Is the Best Treatment

• Universal Prophylaxis: The World Health Organization and most national guidelines recommend a 1 mg intramuscular (IM) injection of vitamin K at birth for all newborns. This dramatically reduces the risk of both classic and late VKDB 1 12 13 14.
• Oral Prophylaxis: Oral regimens are less effective than IM, especially for infants with undetected liver disease or malabsorption. Multiple oral doses are better than a single dose, but compliance can be an issue 1 8 13 15.

Managing Acute Bleeding

• Vitamin K Administration: For infants with active bleeding, vitamin K is given intravenously (IV) or intramuscularly (IM), leading to rapid correction of clotting function and cessation of bleeding 2 3 6 8 12.
• Supportive Therapy: In cases of severe bleeding, plasma or blood transfusions may be required. Neurosurgical intervention is sometimes necessary for intracranial hemorrhage, but carries significant risks 2 3 6 7.
• Treating Underlying Conditions: If secondary VKDB is due to liver disease, malabsorption, or antibiotics, treating the underlying cause is essential to prevent recurrence 1 5 9.

Special Populations

• Preterm and Low Birth Weight Infants: These babies are at greater risk and may require tailored vitamin K dosing, though evidence is limited and current practice extrapolates from term infants 4 16.
• Hereditary VKDB: Lifelong vitamin K supplementation, plasma, or clotting factor concentrates may be needed for rare inherited deficiencies 7.

New Approaches

• Microneedle Delivery: Research is underway into transdermal delivery systems like dissolving microneedles, which may allow safe, easy vitamin K administration in low-resource settings in the future 14.

Conclusion

VKDB remains a significant, yet highly preventable, cause of morbidity and mortality in infants worldwide. Preventing this disease relies on ensuring every newborn receives timely vitamin K prophylaxis, recognizing early warning signs, and understanding the risk factors and causes. Treatment is highly effective when administered quickly. However, the best outcomes are achieved through prevention and awareness.

Main Takeaways:

• VKDB symptoms range from mild bruising to catastrophic intracranial hemorrhage, especially in infants under six months.
• Types of VKDB include early, classic, and late forms, with late VKDB being the most dangerous due to high rates of brain bleeding.
• Causes include newborn physiology, exclusive breastfeeding, malabsorption disorders, maternal medications, missed prophylaxis, and rare genetic conditions.
• Treatment is centered on vitamin K administration, with IM injection at birth as the gold standard for prevention. Oral regimens are less effective, especially in high-risk infants.
• Early recognition and universal prophylaxis are essential to eliminate VKDB and its devastating consequences.

By understanding and acting on these key points, healthcare providers and parents can ensure that VKDB becomes a disease of the past.