#122: Newborn Interventions – Addressing Concerns with Facts and Finesse

October 9, 2024 | By Sam Masur

Audio

Summary:

Join us for our latest episode – a conversation on newborn care essentials that can sometimes become a tricky topic: the hepatitis B vaccine and vitamin K injection. With the expertise of Dr. Ha Nguyen, we’ll explore why these tiny treatments pack a big punch, and how you can ease parental fears with facts. We’ll break down the concerns so you can build up confidence in your conversations with new parents.

Newborn Intervention Pearls

1. Conversations about newborn interventions should start as soon as possible, ideally during the prenatal period.
2. Start conversations about newborn interventions by building a sense of alliance with the family – focus on their goals and how you can support them.
3. Factoids and statistics are helpful, but often it’s more important to listen to families, identify the root cause of hesitancy and approach with curiosity, non-judgment and empathy.
4. In most cases, it is more effective to take a “presumptive” rather than “participatory” approach – start from the assumption that the interventions are expected and normal and then address concerns as they arise.

Newborn Intervention Notes 

The Issue

• Despite definitive evidence about the effectiveness of newborn vitamin K injections and vaccines, the rates of refusal or parental hesitancy are increasing. 
• Hesitancy regarding the newborn interventions has been associated with later hesitancy with other childhood vaccines. 
• Refusal rates for vitamin K injections in the U.S. range from 3% in hospitals to 15% for home births and 31% in birthing centers. 
• Up to 25% of newborns do not receive the birth dose of the hepatitis B vaccine.

Why it Matters

• Without IM vitamin K at birth, vitamin K deficiency bleeding occurs at a rate of up to 1,700 per 100,000 babies. 
• A baby that does not receive a vitamin K injection has an 81 times higher risk of suffering from a late bleed, which often manifests in intracranial hemorrhage with severe prolonged morbidity and a mortality rate as high as 20-50%
• In the US, more than 24,000 infants annually are born to mothers with a chronic HBV infection. Hepatitis B vaccination (even without post-exposure prophylaxis) prevents transmission of the hepatitis B virus in 70-95% of infants born to infected mothers.   
• Currently about 800 newborns become chronically infected each year from HBV exposure at birth. Without routine vaccination, that number would be about 10,000.  Chronic HBV is associated with significant morbidity and mortality, including liver cancer, and is fatal in about 25% of cases. 

Strategies for Successful Conversations

• Start early! Most parents make decisions about newborn interventions before the time of birth. Ideally, conversations about newborn interventions should involve a multidisciplinary approach during the prenatal period.
• Evidence supports taking a “presumptive” rather than “participatory” approach. This normalizes the interventions, the same way we normalize car seat guidelines. Dr. Ha provides the following sample language: “Here are recommended things that we’re going to do to make sure that your baby stays healthy and safe. In the newborn nursery, we give erythromycin ointment, the hepatitis B vaccine and a vitamin K injection. If you’re hesitant about any of these, I’m happy to listen and talk to you about why they’re important.” 
• Start with establishing shared goals. Before jumping into interventions, ask caregivers to share their goals for their baby and their time in the nursery (e.g., successful breastfeeding). Spending time on their goals helps demonstrate that you are there foremost to support them and their child. 
• Identify the root cause for hesitancy – this may require some follow up questions. 
• It can be helpful to ask permission to give more information. For example: “Is it okay if I share some more information to help you with that decision?”

Addressing Vitamin K Key Concerns & Misconceptions

• Is this actually important? Although most parents making these decisions believe that they are well informed, many are not aware of the real risks associated with non-intervention. Ensure that parents are aware that vitamin K deficiency bleeds can be severe and life-threatening, including the risk of intracranial hemorrhage.
• Can we just do it later? This question sets the stage for a positive conversation because the parent is already recognizing the role of vitamin K. Acknowledge the parent showing concern about the risks, and then emphasize the importance of early intervention to reduce the risk for late bleeds.
• I don’t want to cause my baby pain: Recognize that this is tough, but that sometimes parenting involves making hard decisions for a baby because it is important to their health. Highlight that most babies tolerate the injections well and discuss strategies to minimize discomfort such as having the parent skin-to-skin or latching during injection. It can also be helpful to emphasize that the treatments for a bleed are far more invasive than the singular injection. 
• Can we do oral instead? There is emerging evidence on this option, but the research is insufficient at present. One large study showed that oral vitamin k is fully effective in preventing early bleeds but less so with late (riskier) bleeds. There is not an agreed upon oral regimen and it is not FDA approved. In terms of exposure, the volumes are typically much higher than those in the IM vitamin K injections. 
• Can’t my baby get vitamin K from breastfeeding? Unfortunately, there is very limited pass-through of vitamin K in breast milk. 
• What about adverse reactions? Serious adverse reactions are extraordinarily rare in neonates. As with any injection, there is a small risk for injection site bruising or swelling. 
• I don’t want to give my child unnatural/unsafe ingredients. Vitamin K injections have been used in newborns since the 1960s. The ingredients in vitamin K injections are very well studied and FDA approved. Many hospitals use preservative free options at baseline. Other ingredients include natural sorbitol or oleic acid to help the vitamin K to dissolve and glycol to provide viscosity. Emphasize that there are far fewer ingredients and preservatives in the injection of vitamin K than there would be in any treatments required for a bleed. 

Addressing Hepatitis B Vaccine Concerns and Misconceptions

• I had a negative hepatitis B test during pregnancy: A negative test during pregnancy is a “snapshot picture.” While false negatives or miscommunicated test results are uncommon, they are possible. After an initial negative test, a mother can become infected by family members with undiagnosed infections or via contact with blood, body fluids or open sores from close contacts. 
• My baby has an immune system that is not mature enough. This vaccine has been used for a long time, including in premature and very small babies. The vaccine is not a live vaccine and the dose is very small and well-tolerated. Exposures to antigens are a part of life – the baby will almost certainly be exposed to many just driving home – and this small exposures confers immunity to a very harmful virus. 
• I want to wait until the baby is older. Per above, this can be a good starting point because it means that the parent recognizes the importance of the vaccine. It can be helpful in these cases to compare the vaccine to other safety measures we take from birth (e.g., putting the newborn in a car seat) – it is better to do so late than never but the infant will have unnecessary risk in the meantime. 
• What about side effects? Between 2006 and 2022, there were almost 250 million doses of hepatitis B administered and only 227 significant complications. Allergic reactions occur in approximately one out of every 600,000 cases. Even if adverse reactions are underreported (a common concern), it is extremely unlikely that the missed complications would come anywhere close to the risks associated with contracting hepatitis B. 
• Ingredient safety: Some formulations routinely used in hospitals are preservative free (ask your hospital’s pharmacy). This vaccine is not new, and the additives and buffers have significant longitudinal safety data. 

Resources 

• HealthyChildren.Org Vitamin K Injection Overview 
• HealthyChildren.Org Vitamin K Explanation
• CDC Fact Sheet on Vitamin K Deficiency in Newborns 
• CDC Fact Sheet on Hepatitis B Vaccine
• CDC Hepatitis B Vaccine Overview for Families

Goal

Listeners will be able to respond to parental questions and concerns regarding hepatitis B vaccination and vitamin K administration during the newborn phase. 

Learning Objectives

After listening to this episode listeners will…  

1. Explain the rationale for administration of intramuscular vitamin K during the newborn phase. 
2. Identify risks of delayed or non-administration of newborn vitamin K.
3. Describe the rationale for universal hepatitis B vaccination.
4. Describe the unique risks associated with contracting hepatitis B during infancy..
5. Respond to concerns about side effects and safety of vitamin K injection and hepatitis B vaccination during the newborn phase.

Disclosures

Dr. Nguyen reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Engel S, Nguyen H, Masur S, Chiu C, Berk J. “#122: Newborn Interventions – Addressing Concerns with Facts and Finesse”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ October 9, 2024.