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Erythromycin and Vitamin K Prophylaxis in the NewbornLynette Barnhart, RNC, SNNPMagidah Kobty, RNC, SNNP

University of Texas Medical Branch at Galveston School of NursingNeonatal AHAGNRS 5303

1ObjectivesExplain the origin of Erythromycin and Vitamin KReview Texas requirements for administrationBriefly review erythromycin usageBriefly review vitamin K usage Review evidence based practiceDiscuss long term outcomes and management of positive findings

Upon review of this presentation, the learner will understand the following objectives. 2Origin Erythromycin1881 Carl CredeProphylaxis of ophthalmia neonatorum (ON)Gonococcal or Chlamydial infection treatment

(Rai, et al, 2012)(CDC, 2010)Vitamin K (Phytonadione)1894 Townsend1943 Dam and DoisyProphylaxis of Vitamin K Deficiency Bleeding (VKDB) (Hemorrhagic disease, 2012).

Administration of Erythromycin and Vitamin K at birth was initiated to provide prophylaxis of opthalmia neonatorum (ON) and Vitamin K Deficiency Bleeding (VKDB). ON is a type of eye infection that can result in blindness of the infant if not treated appropriately. It is caused by viruses, blocked tear ducts, and sexually transmitted infections of gonorrhea and chlamydia. Gonococcal infections are caused by the bacteria Neisseria gonorrhea while Chlamydial infections are caused by the bacteria Chlamydia trachomatis (CDC, 2010). In 1881, a physician by the name of Carl Crede realized that infants born vaginally to mothers infected with gonorrhea were infected with ON. His correlation of this sexually transmitted infection to ON led to his treatment of silver nitrate in the newborns eyes shortly after delivery (Rai, et al, 2012). Over the years, the use of silver nitrate has been discontinued and replaced with erythromycin ophthalmic ointment for the prevention of both gonorrhea and chlamydia. Vitamin K deficiency bleeding (VKDB) was formerly known as Hemorrhagic Disease of the Newborn and is a life threatening neonatal bleeding disorder. In 1894 Townsend described a bleeding disorder that was self limiting and not like Hemophilia (Hemorrhagic disease, 2012). In 1943 Hendrik Dam and Edward Doisy won a Nobel Prize for the discovery of the association between vitamin K and coagulation factors VII, IX, and X (Hemorrhagic disease, 2012).3Mandatory Erythromycin prophylaxisTexas Health and Safety Code 81.091Physician, nurse, or midwifeAdminister within 2 hours after birthFailure to treatClass B misdemeanor Free of chargeIf family is unable to pay for prophylaxis Parental refusal May result in a CPS referral

(Texas Administrative Code, 2013)

Texas Health and Safety Code 81.091 was made effective in March 16, 1994 and several amendments have been made in 2003, 2008, and 2010. This code states that a Physician, nurse, or midwife in the state of Texas must administer 0.5% opthalmic erythromycin solution to each eye within tow hours of birth. Failure to treat according to this code is considered a Class B misdemeanor. In the event a family is unable to pay for prophylaxis it is administered free of charge. A familys refusal of this prophylactic treatment in the state of Texas may potentially result in a CPS referral. (Texas Administrative Code, 2013)4Erythromycin usage in patient careErythromycin Ophthalmic Ointment USP, 0.5%Topical administration to eyes bilaterally at birthPremature InfantsEyes fused Mechanism of action(Truven Health, 2013).

A ribbon of ophthalmic Erythromycin 0.5% ointment is administered to both eyes within two hours of birth (Truven Health 2013). Premature infants will receive the same dose as term infants. In the even the infant is born with the eyes fused one dose of Erythromycin is to be administered at delivery and a second dose when the eyes open for the first time (Truven Health, 2013). Erythromycin is the only CDC recommended antibiotic ointment for infants in the prevention of opthalmia neonatourm (2010). The solution flows over the conjunctiva and inhibits the protein synthesis of infectious organisms such as Streptococcus pyogenes, Staphylococcus aureus, Haemophilus influenza, Neisseria gonorrhea, and Chlamydia trachomatis (Truven Health, 2013).

5Adverse Effects of ErythromycinMay cause irritation and blurred visionAllergic reaction Rash, swelling, breathing difficulties

(Truven Health, 2013).

Ophthalmic administration of Erythromycin may cause irritation, blurred vision, and/or allergic reactions. Allergic reactions present with rash, swelling, and breathing difficulties (Truven Health, 2013).6Vitamin K prophylaxisCurrently not mandated in TXRecommended by AAPAdministration at deliveryNow rare condition in the United States

(Hemorrhagic disease, 2013)

Although not mandated in the state of Texas, the American Academy of Pediatrics (AAP) recommends every baby receives an injection of Vitamin K immediately after birth (Hemorrhagic disease, 2013). With the implementation of Vitamin K administration after delivery this potentially fatal condition is rare in the United States (Hemorrhagic disease, 2013).7Vitamin K Fat soluble vitaminEssential for function of blood coagulationAt birthReduced vitamin K storesMinimal placental transferAfter birthVitamin K is limited in breast milk

(Van Winckel et al, 2008)

Vitamin K is a fat soluble vitamin that act as a co factor for y-glutaml carboxylase and the modification to y-carboxyglutamate (Van Winckel, et al, 2008). The Y-carboxylated proteins function in blood coagulation (Van Winckel et al, 2008). Newborn infants are at risk for Vitamin K Deficiency Bleeding (VKDB) because Vitamin K has minimal placental transfer and infants are born with reduced Vitamin K stores (Van Winckel et al, 2008). Vitamin K availability in human milk is limited and considered a poor source (Van Winckel et al, 2008). Vitamin K administration at birth is used as prophylaxis against Vitamin K Deficiency Bleeding in newborns.

8VKDBThree classifications Early onsetWithin 24 hoursMaternal drugs that inhibit vitamin K Classic onset24 hours-7 daysDelayed/insufficient feedingsLate onset2-12 weeksExclusive breastfeedingMalabsorption syndromsCholestasis(Lippi & Fanchini, 2011)

There are three classifications of VKDB as a result of no administration of Vitamin K at birth. Early onset occurs within the first 24 hours of life and is most often associated with maternal drugs that inhibit vitamin K, such as anticonvulsants, antituberculosis drugs, cephalosporins, and warfarin (Lippi & Fanchini, 2011). Infants with early VKDB present with a severe cephalic haematoma, intracranial and intra-abdominal hemorrhages (Lippi & Fanchini, 2011).Classic onset occurs between 24 hours and 7 days and is associated with delayed or insufficient feeding (Lippi & Fanchini, 2011). Infants with classic VKDB present with bruising, GI blood loss , bleeding from umbilicus, and puncture sites (Lippi & Fanchini, 2011).Late onset which occurs between 2 weeks and 12 weeks is associated with exclusive breastfeeding, malabsoprtion syndromes and cholestasis (Lippi & Fanchini, 2011). Late VKDB symptoms are severe and present with intracranial hemorrhage 50% of the time (Lippi & Fanchini, 2011). Late VKDB has a 20% mortality rate (Lippi & Fanchini, 2011).9Vitamin K DosageTerm infants0.5mg-1mg IM at birth

Preterm infants (1000gms0.5mg IM at birth