Hemorrhagic disease of newborns: causes, forms, consequences. Causes of hemorrhagic disease of newborns, treatment and consequences

Previously, the term hemorrhagic disease of the newborn was used to describe disorders in newborns associated with traumatic birth or hemophilia. The correct diagnostic term that has been accepted currently involves vitamin K deficiency.

Hemorrhagic syndrome in newborns- this is bleeding of the skin or mucous membranes, which is caused by changes in the links of hemostasis. Researchers have found that hemorrhagic syndrome can be hereditary or acquired.

Hemorrhagic disease of the newborn, which also belongs to this type of syndrome, is a rare bleeding problem that can occur after birth. It is classified depending on the timing of the first symptoms as early, classic or late.

This condition is caused by a deficiency of vitamin K; therefore, hemorrhagic diseases of the newborn are often called VKDB deficiency - vitamin K deficiency bleeding. This syndrome is a potentially life-threatening condition.

Vitamin K plays a key role in blood clotting. Because it is poorly transmitted from mother to child during pregnancy, most babies are born with low supplies of it. required substance in their system.

Classification hemorrhagic disease newborn

VKDB is classified according to the timing of the first symptoms:

• early onset occurs within 24 hours of birth;
• classic onset occurs within two to seven days;
• late onset occurs within two weeks to six months.

Early start of VKDB occurs within the first 24 hours after birth. The baby's risk of developing this condition is higher if the mother takes certain medications during pregnancy, including:

The mechanisms by which anticonvulsants and antituberculosis drugs cause vitamin K deficiency in newborns are not fully understood, but limited research suggests that bleeding may be prevented by administering vitamin K to the mother during the last 2–4 weeks of pregnancy. An injection given after birth to treat early VKDB may be too late to prevent the disease, especially if vitamin K supplementation was not provided during pregnancy.

Classic bleeding usually occurs after 24 hours and already in the first week of life. Classic bleeding occurs in infants who did not receive prophylactic vitamin K at birth.

The prevalence of classic bleeding ranges from 0.25–1.7 cases per 100 births.

Late onset of VKDB is observed in children under 6 months of age. This form is also more common in infants who have not received vitamin K. Risk factors include:

This usually occurs between 2 and 12 weeks of age; however, late onset of bleeding may occur up to 6 months after birth.

Late hemorrhagic syndrome most often occurs in those infants who did not receive vitamin K at birth.

Industrial contaminants in breast milk are also involved in the development of late hemorrhagic syndrome.

More than half of these children have acute intracranial hemorrhage.

Symptoms of hemorrhagic disease of the newborn

If a child has VKDB, it may appear before it starts serious bleeding, with symptoms such as:

warning bleeding that may seem minor

• low weight for your child's age;
• slow weight gain.

Bleeding may occur in one or more areas, including:

• their umbilical cords;
• mucous membranes of the nose and mouth;
• their gastrointestinal tract.

Internal bleeding can be detected by the following symptoms:

• Hematomas, especially around the child’s head and face.
• Bleeding from the nose or umbilical cord.
• Skin color paler than before. Dark-skinned children may have gums that look paler than usual.
• After the first three weeks During life, the white parts of a child's eyes may turn yellow.
• Bloody stools, black or dark and sticky, bloody vomiting.
• Irritability, seizures, excessive sleepiness, or vomiting a lot may be signs of bleeding in the brain.

Causes of hemorrhagic disease of the newborn

For most people the main A dietary source of vitamin K is green leafy vegetables. It is also a byproduct of certain types of bacteria that live in the intestines, but there are a number of reasons why newborns are prone to hemorrhagic disease. Only small amounts of vitamin K are transferred across the placenta during pregnancy. Human breast milk also contains small amounts of vitamin K, and the primary intestinal flora found in breastfed infants does not synthesize it.

Diagnosis and treatment

If your child's doctor suspects If he has VKDB, he must perform blood clotting tests and receive vitamin K injections. If the bleeding stops, the doctor can confirm the diagnosis of VKDB.

Once a child is diagnosed with VKDB, the doctor will determine a specific treatment plan. This may include a blood transfusion if the bleeding is severe.

Long term perspective

The outlook is good for infants with early onset or symptoms of classic disease. However, the later onset of VKDB may be more severe. It poses a higher risk, life-threatening due to intracranial bleeding, which can cause brain damage or death.

Prevention

If you are breastfeeding, you should talk to your doctor about steps you can take to help your baby get enough vitamin K. Every newborn baby should receive a vitamin K injection after birth. This is a preventive measure to protect the child. It is now common practice for neonatal doctors to give babies injections of something called phytonadione soon after birth. This helps protect the newborn from VKDB.

Facts about Vitamin K Deficiency

Vitamins are substances necessary for our body, which we get from food or from food supplements.

Vitamin K is a substance, which the body needs for better blood clotting and stopping bleeding. We get vitamin K from food. It is also produced by bacteria that live in our intestines. Babies are born with very little vitamin K.

Vitamin K deficiency or VKDB in newborns leads to bleeding. Bleeding can occur anywhere inside or outside the body. When bleeding occurs inside the body, it is difficult to notice.

All children, regardless of gender, race or ethnicity, are at higher risk until they begin to eat regular foods, usually between 4 and 6 months of age, and until intestinal bacteria will not begin to produce vitamin K.

The good news is that VKDB is easily prevented by a vitamin K injection into the thigh muscle. One shot given immediately after birth will protect the baby from VKDB.

Yes. Many studies have shown that vitamin K is safe when given to newborns.

The following 3 forms of vitamin K are known:

K 1: Phylloquinone is predominantly found in green leafy vegetables, vegetable oils and dairy products and as prophylactic, is an aqueous colloidal solution.

K 2: Menaquinone - synthesized by intestinal flora.

K 3: Menadione is a synthetic, water-soluble form that is no longer used medicinally due to its ability to produce hemolytic anemia.

What can cause vitamin K deficiency and bleeding problems in children?

Some things may put children at risk of developing VKDB:

Vitamin K deficiency at birth.

Babies whose mothers used certain medications

Infants who have liver disease.

In children with diarrhea, celiac disease, or cystic fibrosis They often have problems absorbing vitamins from the foods they eat.

Babies who do not receive vitamin K at birth are 80 times more likely to develop late-onset VKDB.

Remember that VKDB is easily preventable with just one vitamin K shot at birth.

Fortunately, hemorrhagic disease of newborns is an infrequent phenomenon, occurring in only 2-5 children out of 1000, and doctors encounter its more dangerous late form even less often - 5-20 children per 100 thousand. “So this is definitely not about us,” you will think, and it’s good if you turn out to be right. Otherwise, only lightning-fast reaction parents on alarming symptoms will help save the baby... So, as they say: “forewarned is forearmed.”

Causes of hemorrhagic disease of newborns

The cause of hemorrhagic disease is vitamin K deficiency, which is necessary for normal blood clotting. Its lack leads to various bleedings that pose a danger to the child's life.

Factors contributing to the development of hemorrhagic disease include the mother taking a number of medications during pregnancy (indomethacin, phenytoin, acetylsalicylic acid, antibiotics), immaturity or prematurity of the newborn, perinatal hypoxia, asphyxia, untimely breastfeeding, as well as birth injuries.

Newborns who, according to doctors, are at risk are given a prophylactic dose of vitamin K immediately after birth ( Vikasol).

The causes of late hemorrhagic disease are somewhat different; we will dwell on them in more detail a little later.

Symptoms and treatment of hemorrhagic disease of newborns

Since classical hemorrhagic disease develops in 2-4 days after birth(rarely on the first day), that is, while the child is still in the maternity hospital, parents just need to trust the professionalism of the doctors and not interfere with the treatment of the baby.

The most common symptoms of classical hemorrhagic disease are nose and gastrointestinal bleeding, continuous bleeding from or after. Therefore, if the baby spits up blood, his nose bleeds, the injection site bleeds for a long time, umbilical wound or there is blood on the diaper, do not wait for the next round, ask the neonatologist to examine the newborn unscheduled, because the sooner treatment begins, the greater the chances of success.

If a blood test confirms the diagnosis, the baby should be immediately they begin to treat. Treatment consists of intramuscular injection of vitamin K, plasma and blood transfusions (in especially severe cases). In addition, about 6 times a day the newborn is fed expressed breast milk, which helps stop bleeding due to the fact that it contains thrombokinase.

If the diagnosis is timely and the treatment of hemorrhagic disease is correct, newborns will quickly complete recovery occurs.

Late hemorrhagic disease of the newborn

Late hemorrhagic disease affects children aged 1 to 4 months, most often appearing at 2 months. However, exceptions are possible here too, that is, infants both older than the specified age and younger can get sick. The late form of the disease has a slightly different nature - it is caused by the fact that the intestinal flora is not able to synthesize vitamin K2 in sufficient quantity. This disease is more severe and much more dangerous than the classic version.

Who is at risk? As a rule, these are full-term children who did not receive a prophylactic dose of vitamin K in the maternity hospital and suffer from transient liver failure (indirect sign such insufficiency is jaundice that has not resolved by 1 month) and, oddly enough, are exclusively breastfed. What does it have to do with it breast-feeding? It turns out that the intestines of children fed on mother's milk are populated by flora that does not cope well with the synthesis of vitamin K2, whereas when artificial feeding it's quite the opposite.

The danger of late hemorrhagic disease of newborns is that if treatment is not started in as soon as possible, That large-scale intracranial hemorrhages can't be avoided. High percentage mortality from the late form of this disease is associated precisely with the difficulty of its recognition. Since this phenomenon is considered very rare, not every local pediatrician will be able to interpret the symptoms in a timely manner, and parents are often in no hurry to see a doctor, not realizing that in such a situation literally minutes count.

So, parents should be wary the appearance of bruises on the baby’s body- in any quantity and any size. There is no need to think about under what circumstances the baby could have received such an injury - he rubbed a button from a bodysuit, hit the crib, lay down on a rattle... Don’t look for excuses, but call ambulance, because this is the first alarm bell!

If a baby's blood was taken for analysis, and my finger won't stop bleeding, then this is a sure sign of problems with blood clotting, which means a reason to urgently call doctors. Why such a rush? The fact is that the very first visible symptoms, such as bruises on the body, bleeding, etc., will develop into intracranial hemorrhage in just 1-2 days, so in this issue It’s better to “be on the safe side.”

And finally, I would like to wish your children good health. Let the knowledge gained from this article remain only theoretical, and you will never have the opportunity to put it into practice!

3
1 FSBEI DPO "Russian medical academy Continuing Professional Education" Ministry of Health of the Russian Federation, Moscow; GBUZ "Children's City clinical hospital them. FOR. Bashlyaeva" DZ Moscow
2 Federal State Budgetary Educational Institution of Further Professional Education RMANPO of the Ministry of Health of Russia, Moscow; GBUZ "DGKB im. FOR. Bashlyaeva DZM"
3 GBUZ "DGKB im. FOR. Bashlyaeva DZM"

For quotation: Zaplatnikov, Dmitrieva Yu.A., Shishkina S.V., Kataeva L.A., Brazhnikova O.V., Gavelya N.V. Late hemorrhagic disease of the newborn ( clinical analysis) // RMJ. 2014. No. 21. S. 1547

Among all pathological conditions in children, hemorrhagic disorders occupy a special place, which is due to a potentially high risk of developing serious complications. The reasons for this, as a rule, are late diagnosis and inadequate therapy.

Untimely nosological verification of hemorrhagic syndrome is often due to underestimation of anamnestic data, incorrect interpretation of clinical manifestations, as well as errors in the interpretation of results laboratory examination. In addition, in some cases, the reason for a late diagnosis is terminological confusion, as a result of which a practicing pediatrician may have an erroneous idea about the age limits for certain types hemorrhagic disorders.
Thus, the generally accepted term “hemorrhagic disease of the fetus and newborn” (code P53 according to ICD-10), from a formal point of view, should be used only in cases where vitamin K-deficient coagulopathy is detected in the perinatal period. At the same time, it has been proven that vitamin K deficiency in a child’s body can clinically manifest itself not only during the newborn period, but also in subsequent weeks and even months of life. In these cases they speak of “late hemorrhagic disease of the newborn.” However, the correctness of this term raises reasonable doubts, since it is used to refer to hemorrhagic syndrome that manifests itself in the postneonatal period. The erroneous association of vitamin K deficiency only with the neonatal period creates the prerequisites for ignoring these conditions when searching for the causes of hemorrhagic disorders in children over 1 month of age. Underestimation of the role of vitamin K deficiency in the genesis of hemorrhagic syndrome in the postneonatal period can cause late diagnosis and the risk of developing serious complications. As an example of late verification of vitamin K-dependent coagulopathy, we present our own clinical observation.

Girl aged 1 month. 11 days with a diagnosis of “Gastroduodenal reflux? Esophagitis? was referred by a local pediatrician for hospitalization due to frequent regurgitation and the appearance of brownish streaks in the vomit.
From the anamnesis it is known: the girl is somatically healthy woman 26 years old. From the first pregnancy, which occurred with toxicosis in the first trimester. 1st birth, spontaneous at 38 weeks, physiological. Body weight at birth - 3100 g, height - 51 cm. Apgar score - 8-9 points. Attached to the breast immediately after birth. She took the breast actively. From the 3rd day of life, icterus of the skin was noted, which was regarded as a manifestation physiological jaundice. Vaccinated against tuberculosis and hepatitis B in the maternity hospital. Discharged from maternity hospital on the 4th day in satisfactory condition.
The girl has been breastfed freely since birth. Body weight gain during the first month of life was 1100 g. While breastfeeding, from the first days of life, slight regurgitation after feeding was noted, which was regarded as a manifestation of infant regurgitation; no therapy was carried out. Within 3 weeks. The child retained yellowness of the skin with gradual fading. In 1 week Before hospitalization, regurgitation became more frequent.
Upon admission to the department, the child’s condition moderate severity. Moderate lethargy. Skin pale. On the left shoulder and in the area of ​​the left breast there are dense subcutaneous nodules up to 1.0 and 0.5 cm in diameter, respectively (according to the mother - “due to the clip-on closures on the undershirt”). Mucous membranes are moist and clean. Heart sounds are sonorous, rhythmic, gentle systolic murmur at the apex. Breathing in the lungs is puerile. The abdomen is soft and accessible to deep palpation. Liver +1.0 cm. Stool is independent, mushy, with a small admixture of mucus. Urination is free. There are no focal or meningeal symptoms. Reflux contains scanty streaks of blood.
Upon admission, clinical and biochemical blood tests, a general urine test, and ultrasound of internal organs were performed with an additional assessment of the functional state of the gastroesophageal area (water-siphon test). In this case, mild normochromic, normocytic anemia was detected: HGB 106 g/l, RBC 3.4x1012, MCV 81 fl, MCH 26.1 pg, CP 0.93, moderate thrombocytosis: 612x109. A biochemical blood test revealed slight hyperbilirubinemia ( total bilirubin- 30 µmol/l, direct - 7 µmol/l) and a moderate increase in LDH (1020 units/l). Ultrasound data of internal organs indicated the absence of gastroesophageal reflux, chalasia and pyloric stenosis.
During the 1st day of the child's stay in the department, attention was paid to continued bleeding from the sites where blood was collected for research. Taking into account the persistent hemorrhagic syndrome (bleeding from injection sites, streaks of blood in the vomit), the child underwent (sito!) a clinical blood test with reticulocytes, neurosonography and a coagulogram. At the same time, the anamnesis and clinical data were analyzed in detail, which further revealed the following:
- absence of hemorrhagic diseases in the family;
- during pregnancy and after childbirth (this time period was studied, taking into account the exclusive feeding of the child breast milk) the mother did not receive medications that could affect hemostasis;
- menadione sodium bisulfite was not administered to the child in the maternity hospital;
- streaks of blood in the refluxate appeared within 1 week. before hospitalization;
- clearly limited change in skin color (like “bruises”) up to 0.5 and 1.0 cm in diameter above the “nodules” in the nipple area mammary gland left and left shoulder. Palpation of the indicated tumor-like formation in the area of ​​the left mammary gland revealed hemorrhagic discharge from the nipple. After the outflow of hemorrhagic discharge, the “nodule” ceased to be palpable, but limited blueness of the skin in this place remained. All this made it possible to consider the identified “nodules” as subcutaneous hematomas, which the mother interpreted as a manifestation of skin traumatized by the clips on children’s clothing.
Taking into account the ongoing bleeding and the emerging clinical signs of anemia, immediately after blood sampling, emergency syndromic therapy was started: intravenous administration of menadione sodium bisulfite (1 mg/kg), fresh frozen plasma(FFP) (20 ml/kg), a pressure bandage was applied to the injection sites with a hemostatic sponge.
Analysis of the results of the (cito!) examination revealed changes in the clinical blood test in the form of the appearance of hypochromic hyperregenerative anemia of moderate severity (Hb - 88 g/l, red blood cells - 3.2x1012, color index - 0.83, reticulocytes - 5.3% ), persistent thrombocytosis (621x109) and a normal level of bleeding duration (according to Duque - 2 minutes). At the same time, according to the coagulogram data, attention was drawn to the absence of coagulation along the internal (activated partial thromboplastin time (aPTT) - no clot) and external (prothrombin index - no clot) coagulation pathways with normal levels fibrinogen (3.81 g/l) and the final stage of coagulation (thrombin time (TV) - 15.1 s) (Table 1). Neurosonography data allowed us to exclude intracranial hemorrhagic changes.
The results of the laboratory examination made it possible to diagnose the disorder plasma hemostasis according to the type of vitamin K-dependent coagulopathy. This was supported by:
- absence of disorders of primary hemostasis (neither thrombocytopenia nor prolongation of bleeding according to Duque was detected);
- the presence of disturbances only in those parts of secondary hemostasis, functional activity which is determined by vitamin K. Thus, there was pronounced hypocoagulation in internal and external ways coagulation, while fibrinogen and TV remained within normal limits.
Thus, the anamnesis data clinical picture and the results of the examination made it possible to verify late hemorrhagic disease of the newborn, which determined the need to continue therapy with menadione with sodium bisulfite for another 3 days. It should be emphasized that the hemorrhagic syndrome in the child was relieved after the administration of FFP, while complete normalization of coagulogram parameters occurred only after completion of the course of treatment with menadione with sodium bisulfite (Table 1).
Taking into account the fact that vitamin K deficiency in the child’s body could be caused not only by a nutritional factor (exclusive breastfeeding, characterized by a low vitamin K content), but also by its insufficient synthesis by endogenous intestinal microflora, as well as by a violation of its utilization in the intestine, research was carried out additional examinations. Clinical and laboratory signs no cholestasis or malabsorption was detected. This made it possible to consider the lack of prophylactic administration of menadione sodium bisulfite in the early neonatal period and exclusive breastfeeding as the main provoking factors for the development of vitamin K-dependent coagulopathy in this patient.
Final diagnosis: main - “Late hemorrhagic disease of the newborn”; complications - " Posthemorrhagic anemia moderate"; accompanying - “Infantile regurgitation”. On an outpatient basis, it is recommended to continue breastfeeding if the mother follows a rational diet for nursing women and takes daily multivitamins. To correct anemia, a polymaltose complex of ferric iron (5 mg/kg/day for elemental iron) was prescribed for 1 month. with subsequent monitoring of indicators clinical analysis blood.

Submitted by clinical case indicates the need for the pediatrician to be alert to any, even the most minimal, hemorrhagic manifestations, especially in children early age. At the same time, replacing the widely used term “late hemorrhagic disease of the newborn” with “vitamin K-dependent coagulopathy” will avoid the erroneous association of vitamin K deficiency conditions exclusively with the neonatal period. Inclusion of the specified pathological condition in the list possible reasons hemorrhagic syndrome in children, regardless of their age, will allow timely verification of the diagnosis and prescribing adequate therapy.

Literature
1. Barkagan L.Z. Hemostasis disorders in children. M., 1993.
2. Nelson Textbook of Pediatrics, 19th Edition /R.M. Kliegman, B.M. Stanton, J. St. Geme, N. Schor, R.E. Behrman. New York, London: Elsevier Inc., 2014.
3. Childhood diseases / ed. N.P. Shabalova / 6th ed. St. Petersburg: Peter, 2009.
4. Dolgov V.V., Svirin P.V. Laboratory diagnostics hemostasis disorders. M.: Triad, 2005.
5. Shabalov N.P. Hemorrhagic disorders in newborns / In the book: Neonatology.
In 2 vols. / 3rd ed., rev. and additional M.: MEDpress-inform, 2004. T. 2. P. 208-223.
6. Neonatology. National leadership. Krat. ed. / ed. N.N. Volodina. M.: GEOTAR-media, 2013.
7. Takahashi D., Takahashi Y., Itoh S. et al. Late vitamin K deficiency bleeding in an infant born at a maternity hospital // Pediatr Int. 2014 Jun. Vol. 56(3). R. 436.
8. Van Winckel M., De Bruyne R., van de Velde S., van Biervliet S. Vitamin K an update for the pediatrician // Eur J Pediatr. 2009 Feb. Vol. 168(2). R. 127-134.
9. Hubbard D., Tobias J.D. Intracerebral hemorrhage due to hemorrhagic disease of the newborn and failure to administer vitamin K at birth // South. Med. J. 2006. Vol. 99(11). R. 1216-1220.

Hemorrhagic disease of newborns is a pathology in which a violation of the blood clotting process develops. The root cause of the pathology is considered lack of vitamin K in the body.

The disease manifests itself with characteristic symptoms, the presence of which negatively affects general condition baby. The pathology manifests itself in the first days of the baby’s life (depending on the form).

The pathology is considered quite rare, now with the introduction special preventive measures, associated with vitamin K intake, the incidence is only 0.02% of the total number of newborns (not so long ago these figures were much higher).

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Concept and characteristics

Vitamin K – essential microelement, responsible for the production of enzymes necessary for normal blood clotting.

Vitamin K is produced in the child’s body 4-5 days after birth; up to this point, the microelement enters through the placenta, and then through mother’s milk.

With a deficiency of this substance, the number of enzymes produced and their activity decreases, which leads to disturbances in the blood clotting process and the development of increased bleeding.

Causes

Depending on the form of the pathology, the reasons for its development may be different. The primary form develops due to a lack of vitamin K in the body. Deficiency of this microelement develops due to such unfavorable factors as:

1. Imperfect intestinal microflora(observed in all children in the first days of life). Vitamin K synthesis occurs in the intestines, and disruption of its microflora leads to disruptions in this process.
2. Impaired blood flow in the placenta during the intrauterine period of fetal development. As a result, vitamin K practically does not reach the baby through the placenta.
3. Low micronutrient content in breast milk mother (or the use of low-quality infant formula, if we're talking about about artificial feeding).

The following negative factors increase the risk of developing hemorrhagic disease of newborns:

1. A woman taking some during pregnancy medicines, in particular, antibiotics, anticoagulants.
2. Severe pregnancy against the background of strong toxicosis, gestosis.
3. Diseases of the gastrointestinal tract(liver, intestines) in the expectant mother.

The secondary form of pathology develops as a result of liver diseases, in which the activity of production decreases. plasma factors blood clotting.

Uncontrolled use of drugs that promote the destruction and removal of vitamin K from the body can also lead to the development of the disease.

Provoking factors pathologies are considered:

• the birth of a child ahead of schedule;
• fetal hypoxia;
• disruption of the breastfeeding process (for example, if for some reason the child received intravenous nutrition, or with late breastfeeding);
• disruption of the absorption process nutrients in the intestines;
• diseases of the gastrointestinal tract;
• taking antibiotics.

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Pathogenesis

Impaired synthesis of polypeptide precursors of plasma factors (PPPP), necessary for the production of blood clotting factors, leads to disruption of the production of these factors and a decrease in their quantity.

As a result, there is an increase in thrombosed time (an indicator of external blood clotting) and thromboplastin time (an indicator of the internal clotting pathway).

Classification and forms of the disease

There are primary and secondary forms of pathology. The primary form develops due to the child does not receive enough vitamin K(in the intrauterine or neonatal period of development).

The secondary form manifests itself against the background of diseases of the liver and other organs of the gastrointestinal tract (in particular, the intestines).

With liver pathologies, the production of PPPF decreases; with dysbiosis, an insufficient amount of vitamin K is produced in the intestines. Both of these phenomena can lead to the development of hemorrhagic disease.

Depending on when the first signs of pathology appear, it is customary to distinguish the following types:

• early form. Symptoms appear on the first day after the baby is born. This form is relatively rare. Its development is most often caused by taking medications during pregnancy;
• classical form. It is considered the most common. Signs of pathology develop in the first 4-6 days after the birth of the baby;
• late form. The clinical picture appears several months after the birth of the child. Prerequisites for its development are the presence of diseases of the gastrointestinal tract, insufficient intake into the body of vitamin K.

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Symptoms and clinical picture

Depending on the form of the disease, the clinical picture may be different.

Yes, for early form GrBN manifests itself in the form of such signs as:

• the appearance of a characteristic hemorrhagic rash throughout the body (in the buttock area the rash is more intense);
• internal hemorrhages;
• nausea and vomiting (bloody elements are found in the vomit);

Hemorrhages in internal organs are manifested by the following symptoms:

1. Neurological disorders are a sign of hemorrhage in the brain.
2. Difficulty breathing, discharge of sputum containing blood - with hemorrhages in the organs of the respiratory system.
3. Painful sensations in the abdomen, an increase in the size of the liver - with hemorrhages in the liver.
4. Weakness, loss of appetite - with hemorrhages in the adrenal glands.

At classical form of GRBN The clinical picture is supplemented by the following signs:

• change in stool, appearance of bloody impurities in the stool;
• nosebleeds, bleeding in the navel;
• content of blood elements in urine.

At late form pathology clinical manifestations more pronounced, the child has bleeding of the mucous membranes, extensive internal hemorrhages, and severe anemia.

In some cases, the child may develop hemorrhagic shock. In this case, the child rapidly turns pale, becomes weak, lethargic, it is noted sharp decline, disturbances in thermoregulation processes.

Possible complications

Possible complications of HFN include hemorrhages in internal organs, causing various kinds disruption of their activities, significant deterioration in health child, accompanied sharp decline Blood pressure and body temperature.

In especially severe cases, death may occur.

Differential diagnosis

For staging accurate diagnosis necessary laboratory tests blood, during which its clotting time, platelet level, and hemoglobin level are determined (to identify anemia).

If there are bloody elements in the stool, it is necessary to carry out differential diagnosis, which makes it possible to distinguish GRBN from Swallowed Blood Syndrome.

For this carry out special test: a small amount of baby's stool is diluted with water to obtain liquid pink shade. The resulting solution is sent to a centrifuge to obtain a precipitate.

A small amount of liquid released after precipitation is mixed with sodium hydroxide solution.

After 2 min. evaluate the result: if the liquid turns brown - Swallowed blood syndrome occurs, if its color remains pink, the stool contains the baby’s blood, which may indicate the presence of GRBN.

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Treatment

Basic therapeutic method –administration of preparations containing vitamin K.

Most often used Vikasol at a dosage of 0.1 mg. drug per 1 kg. child's weight.

Injections are carried out intravenously or intramuscularly for 2-3 days, once a day. All this time, it is necessary to strictly control the amount of vitamin K in the child’s body, since its excess can lead to the development of adverse consequences.

If there are extensive internal bleeding the child is prescribed a transfusion fresh frozen plasma products, high concentration prothrombin complex.

If anemia develops, the patient requires a red blood cell transfusion to restore hemoglobin levels.

Throughout the entire treatment period, the child must breast-feeding, since in mother's milk contains elements that help accelerate the process of blood clotting. If breastfeeding is not possible, a woman is advised to express milk for breastfeeding.

On the diagnosis and treatment of hemorrhagic disease of newborns.

Prevention

Administration of vitamin K to the newborn will help prevent the development of dangerous symptoms of the pathology. This measure is indicated for children who have the risk of developing GRBN is increased. These children include:

Expectant mother during the waiting period baby, must comply necessary measures precautions. In particular:

1. Before taking medications, you should consult with your doctor monitoring your pregnancy.
2. Take measures to prevent gestosis, dysbiosis, and significant hormonal imbalances.

dangerous disease manifesting itself in a number of ways characteristic symptoms, among which we can note the presence of internal bleeding.

This symptom disrupts the functioning of internal organs and worsens the child’s health. Extensive hemorrhages can cause death. Therefore, the disease requires urgent treatment with medications and replacement therapy.

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We kindly ask you not to self-medicate. Make an appointment with a doctor!

Unfortunately, even after a successful birth and a positive assessment of the baby’s condition by doctors, not everyone can hope that they will not have health problems. Some diseases appear a little later, but are very dangerous and insidious. For example, hemorrhagic disease of newborns can be diagnosed both by the third day after birth and more late period when mother and child are already at home. It can sometimes be very difficult to suspect this pathology, but it needs to be done, because with such a problem, life can count for minutes!

Features of the disease

In the list of coagulopathies, or diseases related to disorders of the blood clotting system, not the last place is occupied by the most serious pathology - hemorrhagic disease of newborns. It is a disease of recently born children, which is associated with increased bleeding of the skin and internal organs due to insufficiency of blood clotting factors, in particular due to vitamin K deficiency.

In most cases, coagulopathy belonging to the group hemorrhagic diathesis, develops already between the end of the first and the end of the third day after birth. As a result of a lack of vitamin K in the baby's body, an acute deficiency of coagulation factors (thrombin index factors) - II, VII, IX, C, S, X - occurs. Since the disease is directly related to the neonatal period, it is considered congenital. The incidence of hemorrhagic disease of newborns in different countries is 0.25-1.5%, but in recent years in many countries due to early parenteral administration vitamin K, this figure dropped to 0.01% or less.

Causes of the disease

Vitamin K in the body of any person is responsible for activating the phenomena of gamma-carboxylation of glutamic acid in coagulation factors, which are listed below:

• prothrombin (II);
• proconvertin (VII);
• antihemophilic globulin B (IX);
• Stewart-Prower factor (X).

Also, the role of vitamin K is great in the proteins of the anticoagulant system (C, S), in osteocalcin and many other proteins. If this vitamin is not enough in the child’s body, then the thrombin index factors remain inactive and cannot bind calcium and carry out the blood clotting process. Early forms of hemorrhagic disease of newborns are associated with the fact that vitamin K very poorly penetrates the mother’s bloodstream through the placenta, so initially there is not enough of it in the newborn’s body (only 50% of the required value). Only by 3-5 days from birth does vitamin K begin to be actively produced by microorganisms inhabiting the intestines. Before this period, the prothrombin time may be prolonged, as well as the activated partial thromboplastin time, which causes the appearance of symptoms of hemorrhagic disease of the newborn.

However, the frequency of this disease is quite low, that is, the triggering of the mechanism of coagulopathy does not occur in all newborns. In healthy children, even taking into account the low content of vitamin K in the body, the hemostasis system works stably. Early forms of pathology arise, as a rule, under the influence of factors related to events or diseases of the mother’s body during pregnancy. The main ones are listed below:

• taking Aspirin, NSAIDs;
• long-term treatment with indirect anticoagulants;
• reception anticonvulsants, antibiotics of some groups wide range actions;
• carrying out specific treatment tuberculosis;
• intestinal dysbiosis;
• liver diseases;
• enteropathy;
• gestosis;
• a serious decrease in estrogen levels.

Also, hemorrhagic disease of the newborn occurs more often in premature babies born at the wrong time. In such babies, the liver’s production of PPPF, polypeptide precursors of plasma blood coagulation factors, is reduced. This can happen with some liver diseases - hepatitis, biliary atresia. In addition, there is late hemorrhagic disease, which is caused by a number of pathogenic factors on the part of the child’s body. So, the synthesis of vitamin K may be impaired, which happens for the following reasons:

• long-term parenteral nutrition;
• malabsorption syndrome;
• taking vitamin K antagonist drugs, for example, Neodicoumarin, Coumarin;
• intestinal immaturity;
• late breastfeeding;
• artificial feeding;
• taking broad-spectrum antibiotics, especially 3rd generation cephalosporins;
• perinatal hypoxia;
• birth by caesarean section;
• asphyxia during childbirth;
• birth injuries.

Despite the fact that breast milk contains an insufficient amount of vitamin K for the child’s body, early breastfeeding seriously reduces the likelihood of developing hemorrhagic disease of the newborn, since lactation promotes an earlier colonization of the intestines with microflora and the beginning of the production of this substance directly in the child’s body.

Classification and symptoms

The classification of hemorrhagic disease of newborns includes two types:

1. Primary hemorrhagic disease. Occurs when the child’s blood levels of vitamin K are initially low.
2. Secondary hemorrhagic disease. Includes a violation of the production of PPPF blood clotting due to liver disease and other pathologies and risk factors.

In addition, the disease is divided into three forms:

1. The early form occurs on the 1st-2nd day of a child’s life and is characterized by high tissue bleeding.
2. The classic form develops on the 3rd-5th day of a baby’s life, bleeding appears by this time.
3. The late form is possible from the 2nd to the 8th week after the birth of the child, its consequences can be very serious, as most often they include hemorrhages in the brain and internal organs.

The early form of the disease develops very difficult. Usually it appears immediately after birth, no later than the end of the first or second day. It most often manifests itself in the form of cutaneous hemorrhagic syndrome - rashes with hemorrhages on the buttocks, and sometimes throughout the skin. If the pathology began in utero, after birth, swelling is noticeable on the baby’s head - cephalohematomas, on which pinpoint hemorrhages - petechiae - are noticeable. Blood is also observed in the child’s stool, it is possible bloody vomiting(hematemesis) and melena - black blood-colored stool. Severe manifestations of the early form of the disease can include pulmonary hemorrhages, hemorrhages in the skull, spleen, liver, and adrenal glands. The amount of hemoglobin in the blood drops, and anemia develops.

Symptoms of the classic form of the disease may be:

• weakness, lethargy of the child;
• cutaneous hemorrhagic syndrome, the appearance of bruises, petechiae and ecchymoses on the skin;
• umbilical bleeding when the remainder of the umbilical cord falls off, bleeding that does not stop after circumcision of the foreskin;
• edematous-hemorrhagic syndrome - swelling on the head and body with areas of hemorrhage;
• recurrent nosebleeds;
• bloody vomiting, blood in the stool ( intestinal bleeding) against the background of the formation of ulcers and erosions in the small intestine;
• increased bilirubin due to the breakdown of red blood cells in the blood and intestines;
• intracranial hemorrhages with neurological symptoms;
• shortness of breath, cough with bloody streaks, reflecting pulmonary hemorrhage;
• symptoms acute abdomen against the background of hemorrhages in the liver;
• lack of appetite, falling motor activity, pain in the back due to hemorrhages in the adrenal glands;
• the appearance of blood in the urine due to bleeding in the kidneys;
• severe anemia.

Typically, the most severe hemorrhages and hematomas in the brain appear in children who were born prematurely, with severe hypoxia, and birth injuries. Babies with liver pathologies and other serious abnormalities in the digestive system may develop a late form of hemorrhagic disease of newborns. As a rule, it occurs no later than the end of the second month of the baby’s life, but cases of the development of pathology within 10-12 weeks have been recorded. In half of the patients, the disease begins with intracranial hemorrhage, which is preceded by large and multiple, but sometimes small, single bruises on the skin. Other possible symptoms:

• bleeding into internal organs;
• melena - blood in stool;
• vomiting blood;
• extensive hemorrhages in the mucous membranes and skin;
• hematuria;
• anemia;
• cephalohematomas;
• bleeding from the injection area.

Thus, the development of a hemorrhagic disease should be suspected when bruises are detected on the baby’s body, especially on the chest, because a child of this age could not hit himself. You also need to urgently call an ambulance if, after taking blood for analysis, the child’s finger continues to bleed for a long time, which with 100% accuracy reflects the presence of any problems with blood clotting. Within a few hours or a couple of days initial symptoms will develop into more severe problems, so the importance of early consultation with a doctor is undeniable.

Possible complications

The danger and severity of this disease is very high. The risk is especially serious in the late form of the pathology, which develops when the child is outside the walls of the maternity hospital without the supervision of doctors, and its initial symptoms can be erased and blurred. It is with the late form that intracranial hemorrhages cannot be avoided if treatment was not started at the earliest early dates. The difficulty of recognizing hemorrhagic disease of newborns in a late form and its rarity determines high mortality at this stage, because not every local pediatrician is familiar with the symptoms of the disease.

Possible complications of hemorrhagic disease of newborns may include:

• fall blood pressure and temperatures up to critical numbers;
• ischemic necrosis of the skin of the legs, arms, abdomen;
• severe hemorrhages in internal organs up to their dysfunction and cessation of work.

The prognosis for recovery is favorable only with mild forms of the pathology and early initiation of treatment. If the functioning of the lungs, heart, kidneys and other organs is impaired, with serious blood loss and cerebral hemorrhage, the prognosis is poor and the risk of death is high.

Diagnostic methods

When conducting an examination and physical examination, the doctor pays attention to the presence of cutaneous hemorrhagic syndrome in the form of hemorrhages and pinpoint petechiae, hematomas. Other signs of bleeding are possible - melena, bloody vomiting, etc. Instrumental examinations a child usually includes an ultrasound of the kidneys, liver, adrenal glands, neurosonography, and ultrasound of the heart.

Laboratory blood tests can confirm the diagnosis. The blood clotting time is prolonged (PT - prothrombin time, APTT - partial thromboplastin time), the platelet count is increased or close to normal, and normal bleeding time (TV - thrombin time) is noted. Anemia is also detected - a decrease in the number of red blood cells, hemoglobin, and hematocrit. By 2-3 days of hemorrhage, anemia can be pronounced.

It is mandatory to differentiate hemorrhagic disease of newborns from other anomalies and pathologies of the first days of life. Thus, melena should be distinguished from the child ingesting the mother’s blood during childbirth, which occurs in 30% of children with blood in the stool in the first day of life. To do this, feces or vomiting blood is taken for analysis using an Apta-Downer test. Aqueous solution the raw materials are centrifuged, special reagents are added and the type of hemoglobin is determined. Hemoglobin type A is characteristic of the mother's blood, other cases are due to the presence of the child's own blood.

Bleeding from the intestines when hemorrhagic disease of newborns is suspected is also differentiated from anorectal trauma, intestinal angiomatosis, papillomas, etc. surgical problems. It is necessary to distinguish the pathology from other hereditary (congenital) coagulopathies, from disseminated intravascular coagulation syndrome, and from thrombocytopenic purpura.

Treatment methods

Treatment methods for hemorrhagic disease of newborns should be used in combination, and the start of therapy is practiced from the first minutes after the appearance of the first signs of the early or classic form of the pathology. The following treatment methods are used:

1. Feeding the baby up to 7-8 times a day with expressed breast milk from the mother is normal, corresponding to age requirements. If the pathology is accompanied by thrombocytopenic purpura, then feeding is continued for at least 3 weeks.
2. Intravenous vitamin K, in mild cases intramuscular injection. The dosage is 1-2 mg, the interval of use is every 12 hours.
3. Administration of Vikasol, a hemostatic drug (replaces the use of vitamin K, but is less effective). Dose - from 2 to 5 mg. in 12 hours.
4. For recurrent bleeding - intravenous transfusion of fresh or frozen plasma, administration of prothrombin complexes PP5B (Prothromplex, Octaplex).
5. Infusion of sodium bicarbonate solution, thrombin solution with aminocaproic acid, non-caproic acid solution with Adroxon solution.
6. Treatment with ascorbic acid, Rutin, calcium gluconate, calcium chloride, calcium pantothenate.
7. If necessary, glucocorticosteroids and antibiotics are introduced into the course of treatment.
8. If hypovolemic shock occurs, red blood cell transfusion and intensive infusion therapy are given.

All measures for the treatment of hemorrhagic disease of newborns are carried out under the constant supervision of a neonatologist.

What not to do

It is prohibited to administer excessive doses of hemostatic drugs due to high risk the appearance of Heinz bodies and the development of hyperbilirubinemia due to increased hemolysis of red blood cells. On the part of the child’s parents, under no circumstances should they hesitate to go to the hospital if even small bruises are detected on the baby’s skin and other alarming symptoms.

Preventive measures

To prevent pathology, all premature babies are administered 0.5 mg. vitamin K once after birth, and for children born on time and with normal weight body - 1 mg. intramuscularly or orally. It is especially important to administer the drug to children who were born with asphyxia and birth trauma, as well as from mothers whose pregnancy proceeded with toxicosis, or whose baby was infected in utero.

Early latching of the baby to the breast after birth is also a good prevention of the disease, but this method does not replace the administration of drugs to optimize blood clotting. If a woman has already given birth to children with hemorrhagic disease of the newborn from previous pregnancies, then they spend the entire gestation period under constant medical supervision, and before birth - in a hospital.