So, You Have A Plan
Maybe it involves a hot rock massage as you sway back and forth on your birth ball, or fresh, clean sheets made up just for you at a mother-friendly hospital. You’ve decided whether to delay cord clamping and who gets to catch the baby, but you’re stuck on the vitamin K shot.
On the one hand, you have a feeling that our bodies are pretty wise, and if vitamin K is naturally low in newborns maybe there’s a good reason. On the other, you know that 100% breastfed babies are the most likely to suffer from life-threatening Vitamin K Deficiency Bleeding (VKDB). It’s confusing to say the least.
Today I’m going to share my personal process in deciding whether my three children would receive the Vitamin K shot, oral Vitamin K, or no supplementation. Please keep in mind that “Best Boo-Boo Kisser South Of Puckett’s Gas Station” is about as official as things get for me professionally. I am not a doctor, this is not medical advice, and your decision is completely up to you. If you need some convincing on this, read my full disclaimer where I say it over and over again. Okay, let’s jump in!
“K” is For Koagulation
Vitamin K is a fat-soluble vitamin that derives it’s name from the German word “koagulation.” (source) As you’ve probably guessed, that’s because it’s essential for helping blood clot appropriately when needed.
In newborns, adequate Vitamin K levels are needed to prevent Vitamin K Deficiency Bleeding (VKDB), a rare but life-threatening condition that cause cause uncontrolled bleeding, sometimes into the brain.
There are three types of Vitamin K Deficiency Bleeding:
- Early VKDB presents within 24 hours of birth. It is “almost exclusively seen in infants of mothers taking drugs which inhibit vitamin K. These drugs include anticonvulsants (carbamazepine, phenytoin and barbiturates), antituberculosis drugs (isoniazid, rifampicin), some antibiotics (cephalosporins) and vitamin K antagonists (coumarin, warfarin). “
- Classic VKDB presents between day 1 and day 7 of life and is associated with delayed or insufficient feeding. It usually affects the gastrointestinal tract, skin, nose, gums, umbilical stump and circumcision site, if applicable.
- Late VKDB presents between week 2 and six months, with the majority of cases occurring between 3-8 weeks of age. Late VKDB has the highest mortality rate of all types and is more likely to lead to neurological damage, but it is also the most rare.
What Are The Risk Factors?
The primary risk factors of Vitamin K Deficiency Bleeding are thought to be:
- Breastfeeding – More on this below.
- Maternal Use Of Medications, Including Antibiotics – As mentioned above in the section on early VKDB, “Antibiotics, particularly a class known as cephalosporins, reduce the absorption of vitamin K in the body. Long-term use (more than 10 days) of antibiotics may result in vitamin K deficiency because these drugs kill not only harmful bacteria but also beneficial, vitamin K-activating bacteria. This is most likely to occur in people who already have low levels of vitamin K or are at risk for deficiency (such as those who are malnourished, elderly, or taking warfarin). (source) Other medications can also interfere with Vitamin K.
- Certain Health Conditions – If baby has undiagnosed cholestasis (liver problems), diarrhea, hepatitis, cystic fibrosis (CF), celiac disease, or alpha – 1-antitrypsin deficiency, or a genetic variation affecting Vitamin K absorption, they may be at increased risk for VKDB. (source)
Other factors are preterm delivery, low birth weight, and possibly traumatic delivery. Antibiotics given to a newborn may also affect their ability to generate Vitamin K2 within their digestive tract.
Why Is Breastfeeding A Risk Factor?
I’m so glad you asked. According to most healthcare professionals, the answer is that human breast milk is low in Vitamin K.
But WHY is breast milk low in Vitamin K, and is this true for ALL women?
Ahhh, that’s where things get interesting. When Dr. Weston A. Price studied the diets of traditional cultures, he discovered what he called “Activator X,” which was found in the special foods “given to pregnant and lactating women, as well as to the maturing boys and girls, in preparation for future parenthood. Dr. Price found these foods to be very rich in fat soluble vitamins A, vitamin D and Activator X —nutrients found only in animal fats.” (source)
After 60+ years of searching, it was discovered that “Activator X” is Vitamin K2. (source)
Interestingly, “When Dr. Price analyzed the foods used by isolated primitive peoples he found that they provided at least four times the calcium and other minerals, and at least TEN times the fat-soluble vitamins from animal foods such as butter, fish eggs, shellfish and organ meats.” (source) In other words, their Vitamin K intake was probably at least ten times higher than ours. Given how much the modern diet has eroded, it’s probably more now.
Why did these cultures emphasize dietary K2 during pre-pregnancy, pregnancy, and breastfeeding? There are probably a lot of reasons, but one of them may have been its affect on VKDB.
Studies On Vitamin K And Breast Milk
It’s important note before we move forward that Vitamin K comes in two main forms: K1 is found in leafy greens, broccoli, brussel sprouts and other fruits/vegetables. K2 is found in animal products like liver, egg yolks, aged cheeses, butter and even fermented foods that contain live bacterial cultures.
Does supplementing moms with Vitamin K raise the levels found in breast milk?
YES. In this large study with over 3,000 mother-infant pairs, Japanese researchers gave babies oral Vitamin K following birth. Some of the babies did not show sufficient improvement, so they implemented maternal supplementation of 15mg of oral Vitamin K2 to 1,856 of the mothers. This method “showed an effective result,” and the researchers concluded that the “transmission of vitamin K through breast milk would be a suitable method of vitamin K prophylaxis.” Prophylaxis is medical jargon for an action to prevent a disease – in this case, VKDB.
One important feature of this study is that it looked at late VKDB – the type that has the highest rate of mortality and neurological damage. According to the study, babies who received early supplementation sometimes experienced a spike in Vitamin K levels that later dropped and put them at risk for VKDB again. Since, according to the researchers, it is “well known that in the pathogenesis of this disease [late VKDB] low levels of vitamin K in breast milk play a crucial role,” they decided to find out if supplementing mothers could sustain higher levels long-term. (emphasis mine) The researchers then explained why they opted for Vitamin K2, stating that “vitamin K2 has an approximately twentyfold higher transfer into breast milk from plasma than vitamin K1.”
In the group of infants whose mothers were given Vitamin K2, only two infants (0.11%) were found to have low infant Vitamin K levels, and none of the infants that were exclusively breastfed had low levels. (Presumably this means some of he infants were supplemented with formula) This is remarkable considering that VKDB rates are considered to be particularly high in Asia. Researchers in another study suggested this may be due to poor diet in rural areas, a genetic component that affects Vitamin K absorption, undetected liver disease/malabsorption issues, and/or breastfeeding rates. (source) Note: Asia may not actually have the highest incidence of VKDB – certain developing countries may as well, possibly due to factors like poor diet, but it may be underreported there.
In one study of preterm infants, maternal supplementation of natural Vitamin K1 (phylloquinone) raised the content of breast milk to target levels. (source)
When women consume vitamin K1 – aka the “plant-based” Vitamin K – their tissues convert part of it into vitamin K2, which is the form prized by the cultures Dr. Price studied. Interestingly, breasts “appear to be especially efficient at making this conversion, presumably because vitamin K2 is essential for the growing infant.” (source 1, source 2) Another study notes that there seems to be a “vitamin K2 concentrating mechanism in the mammary tissue.” (source) In other words, breasts somehow concentrate Vitamin K within mammary glands, presumably to provide this essential vitamin to the baby.
Some researchers have stated their belief that newborn Vitamin K deficiency is likely to be the result of three factors: inadequate dietary intake by the pregnant mother during the last trimester of pregnancy, the fact that babies do not have established gut flora (which produces Vitamin K internally), and inadequate intake by baby after birth.
How Does Colostrum Compare To Regular Breast Milk?
Colostrum – the first milk newborns receive right after birth - contains significantly higher levels of Vitamin K than mature milk. (source)
“In the past, babies were not breastfed till some time after birth, and strict feeding routines were usual; this probably meant that babies got less vitamin K than nature intended. Nowadays, babies are usually breastfeed soon after birth, and they feed frequently for as long and as often as they want. This means they get more colostrum than they used to, reducing the risk of HDN.” (source, emphasis mine)
In other words, unrestricted feeding in the first hour after birth (which is facilitated by skin-to-skin contact) and in the first few days of life may serve as a “quick infusion” of Vitamin K if the mother is eating a nourishing diet and/or taking supplements to ensure she has adequate levels.
Chalk one up for the “wise body” theory.
Does Vitamin K cross the placenta?
YES. According to this study, there seems to be a “highly vitamin K2 specific transport system in the human placenta.“ Vitamin K2 transports across the placenta at a higher rate than K1, and activity increases toward the third trimester. As mentioned in the study, “transport of K1 to the fetus is not especially pronounced,” but while many have interpreted this to mean that there is a “problem” with how efficiently Vitamin K is transported, this study suggests the possibility we may just be looking at the wrong version of Vitamin K. (Though I am citing this study directly, I would like to thank the Weston A. Price Foundation for directing me to it in this excellent article)
Interestingly, the type of Vitamin K that crosses better is the one emphasized in the cultures Dr. Price studied.
Would encapsulating my placenta boost Vitamin K?
Ahhh, great question! In my post about encapsulating my placenta I shared the many reasons I chose to go that route with my third baby. Looking back, there’s a potential benefit I wasn’t aware of: Placentas contain Vitamin K. (source) Biologically, it makes sense to me that consuming placenta while breastfeeding could work synergistically to boost baby’s levels.
However, if the ewwww factor was just too high for me, I would have consumed natural Vitamin K supplements instead.
Why are formula-fed babies less likely to suffer from VKDB ?
According to Evidence Based Birth, “There are virtually no reports of VKDB occurring in infants who are formula fed. This is because in contrast to breast milk, formula has relatively high levels of Vitamin K1—55 micrograms per liter.”
According to some sources, formula contains about 100 times more Vitamin K than breast milk – wow! Though this number is startling, it’s important to know most brands – even the top organic brand of formula – contains phytonadione, a synthetic form of Vitamin K. According to the Organic Consumers Association:
“Certain studies on natural vs. synthetic vitamins have shown that synthetic vitamins are 50 to 70% less biologically active than natural vitamins.
Synthetic vitamins are actually just fractions of naturally-occurring vitamins synthesized in the dextro- and levo- forms (known as “right” and “left handed” molecules) which form geometric mirror images of each other. It may seem strange, but the geometry of nutrient compounds is crucial for the bioavailability of the nutrient. The body uses only the levo- forms. Synthetic vitamin compounds have little of the correct geometry (levo-forms) of naturally-occurring vitamins present in food and botanicals. ” (emphasis mine)
So formula contains gobs of Vitamin K, but much of it may not be biologically active. A well-nourished mother (who may be taking natural Vitamin K supplements per the study above) may have less total Vitamin K in her milk, but some experts believe it is will be more optimally absorbed by baby.
Is there wisdom to low Vitamin K levels?
I believe the answer is yes . . . and no. Breast milk was also once considered inferior because it’s naturally low in iron, but as it turns out there’s a reason for that. In her book Real Food for Mother & Baby Nina Planck says:
“Your milk, and the milk of all mammals, lacks iron. In addition to being iron-poor, milk also contains lactoferrin, which ties up any random iron floating about. At first glance, this seems like an error, given that all living things need iron. With such a firm hand limiting the availability of iron to the nursling we must suspect a deliberate strategy on nature’s part.
Sure enough, there is logic to the missing iron. E. coli, the most common source of infant diarrhea in all species, depends on iron, as do other pathogens. As mentioned in the discussion of prenatal iron supplements, sequestering iron – keeping it out of the way of hungry microbes – is the body’s response to infection.
A low-iron diet protects newborns from iron-loving microbes. As iron expert Sharon Moalem described it to me, lactoferrin is like an armored truck: it transports iron safely to its destination, protecting it from marauding bacteria. Breast milk, in other words, is iron-poor by design. What iron it contains is easily aborbed by your baby.” (emphasis mine)
So there are times when we assume biological error where there isn’t one. Having said that, I believe the levels we’re now seeing are probably below what’s intended by nature. Vitamin K deficiency bleeding has occurred even when a mother’s Vitamin K levels were “normal,” but based on the work of Dr. Price my guess is that our “normal” is really a very poor representation of healthy Vitamin K status. Remember, the indigenous groups he studied consumed at least ten times the amount of fat soluble vitamins that we do.
So What Are My Options?
Let’s compare the modern medical approach to a nutrient dense diet and oral supplementation.
Newborn Vitamin K Shot
Some people believe that the ingredients in the Vitamin K injection are toxic to a baby’s delicate, immature immune system. Let’s take a look at them:
Ingredients (May vary slightly by manufacturer): 2 mg Phytondione (the synthetic version of phylloquinone), 70 mgs polyoxyethylated fatty acid, 37.5 mgs hydrous dextrose, 9 mg benzyl alcohol, and possibly hydrochloric acid. (source) Note: I believe this dose may be cut in half, since .5 -1 mg Phytondione is usually what’s recommended. This was the amount I saw on a single-dose bottle, though.
Ingredients In The Preservative-Free Version (May vary slightly by manufacturer): 1 mg Phytonadione (the synthetic version of phylloquinone), 10 mg Polysorbate 80, 10.4 mg of Propylene glycol, 0.17 mg of Sodium acetate anhydrous, 0.00002 mL of Glacial acetic acid (source)
Benefits Of The Vitamin K Shot
It is very effective at reducing VKDB.
Risks Associated With The Vitamin K Shot
Severe Reactions, Including Death (Rare)
According to the U.S. National Library of Medicine, “Severe reactions, including fatalities, have occurred during and immediately after INTRAVENOUS injection of phytonadione, even when precautions have been taken to dilute the phytonadione and to avoid rapid infusion. Severe reactions, including fatalities, have also been reported following INTRAMUSCULAR administration. Typically these severe reactions have resembled hypersensitivity or anaphylaxis, including shock and cardiac and/or respiratory arrest. Some patients have exhibited these severe reactions on receiving phytonadione for the first time. Therefore the INTRAVENOUS and INTRAMUSCULAR routes should be restricted to those situations where the subcutaneous route is not feasible and the serious risk involved is considered justified.” (bold emphasis mine)
The NLM also states that “Benzyl alcohol as a preservative in Bacteriostatic Sodium Chloride Injection has been associated with toxicity in newborns. Data are unavailable on the toxicity of other preservatives in this age group.” (source) The NLM also says that there is “no evidence to suggest” that the 9mgs contained in the shot are enough to be toxic. However, one study that specifically examined this issue found that the newborn detoxification system needed to process benzyl alcohol is very immature, adding that they “cannot directly answer the issue of safety of ‘low doses’ of benzyl alcohol as found in some medications administered to neonates.” (source)
Benzyl alcohol has been reported to be associated with a fatal ‘Gasping Syndrome’ in premature infants, says NLM.
It is unclear whether all preservative versions contain Aluminum, but at least the Hospira version does:
“WARNING: This product contains aluminum that may be toxic. Aluminum may reach toxic levels with prolonged parenteral administration if kidney function is impaired. Premature neonates are particularly at risk because their kidneys are immature, and they required large amounts of calcium and phosphate solutions, which contain aluminum.
Research indicates that patients with impaired kidney function, including premature neonates, who receive parenteral levels of aluminum at greater than 4 to 5 mcg/kg/day accumulate aluminum at levels associated with central nervous system and bone toxicity. Tissue loading may occur at even lower rates of administration.“
In other words, they’ve observed damage at 4-5 mcg/kg/day, but it could be collecting in tissues well before that.
NLM also states that “hemolysis [the breakdown of red blood cells], jaundice, and hyperbilirubinemia in neonates, particularly those that are premature, may be related to the dose of Vitamin K1 Injection.” (source)
A study published in 2004 “found that very early pain or stress experiences have long-lasting adverse consequences for newborns, including changes in the central nervous system and changes in responsiveness of the neuroendocrine and immune systems at maturity.” (source)
Oral Vitamin K-1
In the U.S., Scientific Botanicals makes an oral K-1 that doesn’t contain any preservatives or synthetic components. K-Quinone is an extract of alfalfa, nettles and green tea that is preserved in a base of olive and soy oil. The soy oil is, unfortunately, not organic and therefore likely to be derived from genetically modified sources.
Benefits Of Oral Vitamin K-1
According to this study which compared newboran oral Vitamin K regimens in Australia, Germany, The Netherlands and Switzerland, a “daily low oral dose of 25 micrograms vitamin K1 following an initial oral dose of 1 mg after birth for exclusively breast-fed infants may be as effective as parenteral vitamin K prophylaxis.”
In other words, after a 1 mg dose on the first day, a low dose of 25 mcg per day starting at 1 week through 13 weeks may be as effective as the shot. Many parents prefer this method because it is not painful to the child and does not involve potentially toxic emulsifiers and preservatives.
Risks Associated With Vitamin K-1
Some babies may spit up the Vitamin K. Certain health problems, like undiagnosed cholestasis (liver problems), diarrhea, hepatitis, cystic fibrosis (CF), celiac disease, or alpha – 1-antitrypsin deficiency may affect Vitamin K absorption.
Parents may forget to administer the Vitamin K daily. (Though it’s certainly possible to remember with the help of smartphone reminders, etc)
Obviously, there is no Cochrane-reviewed study of risks/benefits for this one. Here’s what we know:
1. Breastfeeding is considered a risk factor for VKDB. This may be because modern women are overall deficient in Vitamin K. The populations that Dr. Price studied consumed at least 10x’s the number of fat soluble vitamins that we do.
2. The Vitamin K content of milk increases with a Vitamin-K rich diet and/or supplementation. Babies are at risk for VKDB for the first six months of life, so whatever their source of Vitamin K is needs to be consistently available.
3. Colostrum is higher in Vitamin K content than mature milk – the purpose of this may be to deliver an “infusion” of Vitamin K immediately after birth. Unrestricted feeding practices may increase a newborn’s intake of colostrum. Skin-to-skin contact is thought to be helpful in establishing a good breastfeeding relationship. Moms also might want to check for a tongue or lip tie to increase nursing efficiency.
4. In this study, researchers supplemented moms with Vitamin K-1. What they found was that this increased levels of both K-1 and K-2 in the mother’s breast milk. Unlike other forms of supplementation which focus on just K-1 (synthetic or natural), breast milk contains two forms of Vitamin K.
5. In general, synthetic vitamins are not thought to be as easily utilized by the body as naturally occurring ones.
6. Experts often mention that K-1 does not cross the placenta well. However, it seems less known that Vitamin K-2 crosses the placenta at a higher rate. “When mothers receive injections of vitamin K2, the placenta rapidly accumulates it and then releases it slowly to the fetus over time.” (source 1, source 2)
7. Most mammals consume their placenta after birth. Placenta’s contain Vitamin K. It may be that this is part of an built-in design to provide mothers with a Vitamin K infusion as they begin their breastfeeding journey. I did not encapsulate my placenta with my first two children, but I did with my third. I felt it was beneficial for many reasons, but I would like to note that I craved and scarfed down a lot Vitamin K rich foods following my first two births.
What I Did With My Three Children
I chose the maternal supplementation method for all three of my pregnancies. Each time I did things a little differently, but here was my approach with my last one:
1. I avoided medications during pregnancy and labor. (This was not difficult to do because I didn’t have any need, but with my first pregnancy it is part of the reason I avoided IV antibiotics during labor. I was GBS+, but I chose an alternative approach.)
2. I followed the Weston A. Price recommended diet for pregnant and nursing mothers, which emphasizes Vitamin K2 rich foods.
3. I also drank pregnancy tea, which contains Vitamin K-1 from nettles, during the last trimester.
4. Before I got pregnant I was already supplementing with the MK-7 form of Vitamin K-2. I continued with that.
5. When Levi was born, I waited until the cord completely stopped pulsing before allowing it to be cut. There is little evidence that this affects Vitamin K status, but studies show that babies who have the benefit of delayed cord clamping have 32% more blood by volume. Cord blood contains certain clotting factors that work with Vitamin K, so more blood seemed like a good thing to me. (source)
6. Right after birth I breastfed on demand while consuming a little raw placenta in a smoothie with strawberries, raw milk and maple syrup. It’s not nearly as bad as it sounds, promise. After that I opted to encapsulate the rest of my placenta.
7. For many reasons, I opted not to circumcise either of my sons. Circumcision is often performed while clotting factors are still becoming fully established, and I believe it may place a child at increased risk for VKDB. Boys typically have fewer clotting factors in their blood at birth than girls. (source)
Would I have considered another path if my child had been premature, birth had been traumatic, or circumstances had been different in some way? Yes. I don’t know what decision I would have made, but I I would have definitely considered it. Each parent needs to inform themselves and make a decision based on their circumstances.
A note on supplementing with K-2
I began supplementing with Vitamin K-2 about two years ago for the same reasons listed in this article. Dr. Su Fairchild, and integrative medicine practitioner, has some suggested recommendations regarding dosages here.
Looking For More Info On Birth Choices?
Happy Healthy Child: A Holistic Approach is a DVD childbirth education course that shares insights from over 30 world-renowned OB/GYNs, midwives, pediatricians, scientists, psychologists, childbirth educators, sleep experts and lactation specialists that can help improve the birth experience and overall outcome mama’s and their babies.
If you read through this site much you’l find many of the same names mentioned – these are the people I turned to when I was researching things like routine ultrasounds, co-sleeping, natural birth and more. People like:
- Dr. Bob Sears, who received his pediatric training at Harvard Medical School’s Children’s Hospital in Boston and The Hospital for Sick Children in Toronto — the largest children’s hospital in the world. Dr. Sears is the author of over 30 books on childcare and a fellow of the American Academy of Pediatrics (AAP) and the Royal College of Pediatricians.
- Ina May Gaskin, who has been called “the mother of authentic midwifery
- Dr. James McKenna, head of the University of Notre Dame’s Mother-Baby Behavioral Sleep Laboratory. This post and this post are based on his work.
- and Dr. Sarah Buckley, who was the first to make me dig deeper into routine ultrasounds
Topics covered include:
- Optimal nutrition for you and your developing fetus (I did not agree with all the recommendations in this section. Beautiful Babies is a better resource for dietary recommendations in my opinion.)
- The best ways to prepare for your labor and birth
- Building your birth team
- Overcoming the intensity of labor
- Common interventions and how to avoid the unnecessary ones
- Taking care of your new baby (bonding, breastfeeding, infant sleep, etc.)
What did you do with your little ones?
Photo Credit: Joshua Rappeneker