What treatment should be given to a term newborn with burns, hepatomegaly, and bleeding at multiple sites, with normal Prothrombin Time (PT) and Partial Thromboplastin Time (PTT)?

Treatment for Term Newborn with Burns, Hepatomegaly, and Bleeding with Normal PT/PTT

Give vitamin K immediately (1 mg IM or IV) as this clinical presentation is diagnostic of vitamin K deficiency bleeding (VKDB), which is the only coagulopathy that causes bleeding with normal PT and PTT in newborns. 1, 2

Why This is Vitamin K Deficiency

• Normal PT and PTT with active bleeding in a newborn is pathognomonic for vitamin K deficiency because the coagulation cascade is still partially functional, but vitamin K-dependent factors (II, VII, IX, X) are critically depleted 1, 3
• The hepatomegaly suggests underlying cholestasis or hepatobiliary disease, which dramatically increases risk of VKDB by impairing vitamin K absorption 3, 4
• Burns increase metabolic demands and may worsen existing vitamin K depletion 5
• A prolonged PT with normal fibrinogen and platelet count is "almost diagnostic" of VKDB in a bleeding infant, but early VKDB can present before PT prolongation occurs 3, 4

Immediate Management Algorithm

Step 1: Administer Vitamin K Without Delay

• Give 1 mg vitamin K either IM or slow IV (not exceeding 1 mg per minute) immediately while awaiting laboratory confirmation 2
• Do not wait for confirmatory labs - empiric vitamin K administration is both diagnostic and therapeutic 2
• Expect PT/aPTT correction within 30 minutes to 2-4 hours if VKDB is the diagnosis 1, 2

Step 2: Assess Severity of Bleeding

• If bleeding is life-threatening (intracranial, massive GI bleeding), immediately give fresh frozen plasma (FFP) 10-20 mL/kg in addition to vitamin K for immediate factor replacement 6, 2
• FFP provides immediate coagulation factors while waiting for vitamin K to stimulate endogenous production 6
• Higher vitamin K doses may be necessary if maternal anticoagulants were used 2

Step 3: Verify Vitamin K Prophylaxis History

• Determine if vitamin K was given at birth - compliance varies and some institutions do not mandate it 1
• Breast-feeding is a primary risk factor as breast milk contains insufficient vitamin K 1, 5

Why NOT Fresh Frozen Plasma Alone (Answer A is Incomplete)

• FFP alone does not address the underlying vitamin K deficiency and provides only temporary factor replacement 2
• Vitamin K must be given concurrently with FFP if FFP is used, as FFP does not correct the fundamental disorder 2
• FFP is reserved for life-threatening bleeding requiring immediate hemostasis 6, 2

Why NOT Factor XII (Answer B is Incorrect)

• Factor XII deficiency does not cause clinical bleeding - it only prolongs PTT in laboratory testing 7
• Factor XII is not vitamin K-dependent and is irrelevant to this clinical scenario 6
• The question likely contains an error; no "factor 12" product exists for clinical use

Critical Diagnostic Confirmation

• Rapid correction of PT/PTT within 30 minutes to 2-4 hours after vitamin K administration confirms VKDB 1, 2
• Failure to respond indicates another diagnosis (hemophilia, liver failure, DIC) and requires hematology consultation 2
• Measurement of PIVKA (proteins induced by vitamin K absence) can confirm diagnosis retrospectively 1

Management of Underlying Hepatomegaly

• Investigate cholestasis urgently as this represents secondary VKDB with ongoing malabsorption 3, 4
• Repeated vitamin K doses will be necessary - decide route and frequency based on hepatobiliary function 5
• For infants with hepatic disease, parenteral vitamin K is more reliable than oral due to absorption issues 5, 3

Common Pitfalls to Avoid

• Never delay vitamin K administration waiting for coagulation studies - the diagnosis is clinical and treatment is both safe and diagnostic 2, 4
• Do not assume vitamin K was given at birth without verification 1
• Do not give oral vitamin K to an actively bleeding infant with hepatomegaly - use parenteral route for reliable absorption 5, 3
• Remember that normal PT/PTT does not exclude early VKDB - bleeding can precede laboratory abnormalities 1, 3