What is the immediate management for an infant presenting with a bleed?

Management of an Infant Presenting with Bleeding

Immediately administer vitamin K 1 mg intramuscularly or intravenously (slow IV push, not exceeding 1 mg/min) while simultaneously obtaining coagulation studies, and if the infant is in shock or has severe bleeding, give fresh frozen plasma (FFP) 10-20 mL/kg without waiting for laboratory confirmation. 1, 2

Initial Assessment and Stabilization

Immediate Diagnostic Approach

• Obtain coagulation studies immediately: prolonged prothrombin time (PT) with normal fibrinogen and platelet count strongly suggests vitamin K deficiency bleeding (VKDB) 3
• Look for warning signs: jaundice, failure to thrive, feeding problems, minor bleeding episodes preceding major hemorrhage, or cholestasis 3
• Assess bleeding severity: intracranial hemorrhage occurs in approximately 50% of late VKDB cases and requires urgent neurosurgical evaluation 4

Critical Historical Red Flags

• Vitamin K prophylaxis omitted or refused at birth - the most common cause of late VKDB 4
• Exclusive breastfeeding without vitamin K supplementation 5, 6
• Maternal medications that interfere with vitamin K metabolism (anticoagulants, anticonvulsants) 1, 7
• Cholestatic conditions or malabsorption disorders 6, 3

Immediate Treatment Protocol

For Severe Bleeding or Shock

• Administer FFP 10-20 mL/kg immediately to provide clotting factors while awaiting vitamin K effect (which takes 2-4 hours) 2, 1
• Give vitamin K 1 mg IM or slow IV (not exceeding 1 mg/min if IV route used) 1
• Consider whole blood or component therapy if bleeding is excessive 1
• Monitor for response: PT should shorten within 2-4 hours, confirming VKDB diagnosis 1

For Stable Infants with Bleeding

• Administer vitamin K 1 mg subcutaneously or intramuscularly as first-line therapy 1
• Higher doses may be necessary if mother received oral anticoagulants 1
• Failure to respond within 6-8 hours indicates another diagnosis or coagulation disorder requiring further investigation 1

Special Considerations for Neonates

Blood Product Dosing (Weight-Based)

• RBC transfusion: 10 mL/kg increases hemoglobin by approximately 20 g/L 8
• FFP: 10-15 mL/kg 8
• Cryoprecipitate: 5-10 mL/kg 8, 9
• Platelets: 10-20 mL/kg 8

Neonatal-Specific Requirements

• Use CMV-negative blood products for all neonates 8
• Prescribe blood products by volume, not units 8
• Estimated blood volume: 70 mL/kg in children, up to 100 mL/kg in newborns 8
• Monitor for electrolyte imbalance and hypothermia during rapid transfusion 8

Tranexamic Acid Considerations

For trauma-related bleeding in children: loading dose 15 mg/kg followed by infusion 2 mg/kg/h 8

Important caveat: The adult dose of 1 g tranexamic acid mentioned in guidelines 8 should NOT be used in infants; weight-based dosing is mandatory 8

Rare but Critical Differential: Homozygous Protein C Deficiency

If infant presents with purpura fulminans or extensive thrombotic lesions with bleeding:

• Administer FFP 10-20 mL/kg every 12 hours OR protein C concentrate 20-60 units/kg until lesions resolve 8, 2, 9
• This represents a Grade 1A recommendation from the American College of Chest Physicians 8

Prevention of Future Cases

Documentation Requirements

• Record vitamin K administration (date, dose, route) for all newborns 6
• Document parental refusal if vitamin K prophylaxis declined, given risk of late VKDB 6

Prophylaxis Protocols

Intramuscular route (preferred): Single dose of 0.5-1 mg within 1 hour of birth 1, 6

Oral route alternatives (requires strict compliance):

• 3 doses of 2 mg (at birth, 4-6 days, 4-6 weeks) 6
• OR 2 mg at birth plus weekly 1 mg for 3 months 6

Critical limitation: Oral prophylaxis is NOT appropriate for preterm infants, those with cholestasis, malabsorption, or maternal drug exposure 6

Common Pitfalls to Avoid

• Do not delay FFP administration in severe bleeding while waiting for coagulation studies - empiric treatment saves lives 2, 1
• Do not use adult tranexamic acid dosing (1 g) in infants - always calculate weight-based pediatric doses 8
• Do not assume oral vitamin K prophylaxis was effective - compliance failures are increasingly common 4, 3
• Do not overlook cholestasis as a cause of secondary VKDB even with prior vitamin K prophylaxis 6, 3
• Avoid crystalloid/colloid resuscitation during active hemorrhage unless profound hypotension with no blood products available 8