What is the appropriate work up for a newborn with bleeding?

Appropriate Work-up for a Newborn with Bleeding

A newborn with bleeding requires immediate evaluation for hemorrhagic disease of the newborn (vitamin K deficiency bleeding), coagulation disorders, and trauma, with prompt administration of vitamin K 1 mg intramuscularly or subcutaneously as first-line treatment. 1

Initial Assessment and Management

• Assess the severity and location of bleeding to determine urgency and potential causes 2
• Implement safe handling practices to protect the neonate's skin and prevent further trauma during examination 2
• Administer vitamin K 1 mg subcutaneously or intramuscularly as empiric treatment for suspected hemorrhagic disease of the newborn 1
• Obtain blood samples for coagulation studies before vitamin K administration when possible, but do not delay treatment 1
• Use experienced practitioners for blood draws to minimize trauma and reduce the need for multiple attempts 2

Laboratory Evaluation

• Complete blood count with platelet count to assess for thrombocytopenia 2
• Coagulation profile including prothrombin time (PT), partial thromboplastin time (PTT), and fibrinogen level 2
• If fibrinogen deficiency is suspected, obtain both fibrinogen activity and antigen levels 2
• Consider testing for specific factor deficiencies if initial coagulation studies are abnormal 2
• Limit blood volume drawn, prioritize tests, and cluster testing to minimize trauma and blood loss 2

Specific Evaluations Based on Clinical Presentation

For Mucocutaneous Bleeding:

• Evaluate for epidermolysis bullosa with careful skin examination 2
• Place notices around the cot alerting staff to risk of trauma and need for preventative care 2
• Use emollient or padding between gloved hands and neonate to reduce friction on skin 2

For Intracranial Hemorrhage:

• Consider cranial ultrasound or MRI to evaluate for intracranial bleeding 2
• Monitor neurological status closely 2
• Treat dehydration and anemia if present 2

For Gastrointestinal Bleeding:

• Evaluate for pyloric atresia, especially with bilious or repetitive vomiting or abdominal distention 2
• Consider ultrasound exploration if pyloric atresia is suspected 2
• Maintain fluid balance records 2

Management Based on Suspected Etiology

Hemorrhagic Disease of the Newborn:

• Administer vitamin K 1 mg subcutaneously or intramuscularly 1
• Higher doses may be necessary if the mother has been receiving oral anticoagulants 1
• A prompt response (shortening of prothrombin time within 2-4 hours) following vitamin K administration is usually diagnostic 1

Congenital Fibrinogen Disorders:

• For afibrinogenemia or severe hypofibrinogenemia, consider fibrinogen replacement targeting levels ≥1.5 g/L 2
• Collaborate between neonatal and pediatric bleeding disorder teams 2
• Delay elective invasive procedures until diagnosis is confirmed 2

Epidermolysis Bullosa with Bleeding:

• Contact specialist hospital for guidance if EB is suspected 2
• Consider hospital transfer to an EB specialist hospital 2
• Implement preventative care for all procedures to minimize skin trauma 2

Special Considerations for Procedures

• For intravenous cannulation, use experienced practitioners and secure with low-adherent tape 2
• For blood pressure monitoring, use padding or clothing between cuff and skin 2
• For oxygen monitoring, use soft cotton or silicone dressing between monitor and skin 2
• For temperature monitoring, use axillary temperature probes with emollient 2

Follow-up Care

• Ensure access to a multidisciplinary team for ongoing care 2
• Develop a comprehensive home-care plan before discharge 2
• Identify and prepare in-home caregivers for potential complications 2
• Schedule appropriate follow-up with specialists based on the determined etiology 2

Common Pitfalls and Caveats

• Do not delay vitamin K administration while waiting for diagnostic tests in a bleeding neonate 1
• Avoid adhesive products directly on the skin, especially if epidermolysis bullosa is suspected 2
• Do not lift neonates under the arms; use side roll technique, holding under neck and nappy 2
• Avoid excessive blood draws which can worsen anemia and contribute to hemodynamic instability 2
• Remember that whole blood or component therapy may be indicated if bleeding is excessive, but this does not correct the underlying disorder 1