UK Midwifery Archives
- General issues
- Vitamin K administration for vegetarians
- When Vitamin K may be unwise…(FVL blood clotting disorder)
Some of the material on this page was published in MIDWIFERY MATTERS, Winter 1999, Issue No. 83
This column is compiled from the UK Midwifery mailing list. Open to midwives, students, mothers, and anyone interested in improving maternity services in UK.
I am an independent midwife working in the UK.
Policy throughout all UK health authorities (NHS) is to give routine I/M (intramuscular) dose of vit K in the first hour following delivery. If the parents refuse I/M, then 3 x oral dose is recommended.
I start my discussion of the issue with women by giving them the NHS party line as above, and explain what HDN (haemorrhagic disease of the newborn) is, and which babies are most at risk.
I then talk about the fact that globally all babies are born with low levels of vit K, and all breastfeeding women have low levels of vit K in breastmilk during the early postnatal period. Now why? Is there perhaps a protective mechanism at work which we have not yet found out about? I give out a photocopied article about this (Slattery J. British Journal of Obstetrics and Gynaecology, vol 103, no 5, May 1996, pp400-401). I also give out a useful little article in dialogue form giving the risk statistics and the question of possible association with childhood cancer in easily understandable form (Sally Yarnley. MIDIRS Midwifery Digest, Sep 1992, 2:3, p363). I also give out a more recent update on the arguments and most recent research (New Generation Digest, June 1998, pp12-13).
I always talk about how individual and difficult the decision may be for each couple, and the importance of reaching agreement between them about it. I usually link it with the immunisation issue – if the couple don’t want the baby immunised, they probably will decide they don’t want vit K either, on similar grounds of meddling with immature systems which we do not fully understand.
At the next visit the couple will hopefully have read and discussed the papers and reached their decision. I will support that decision whatever it is.
If following birth there are circumstances which suggest that vit K administration might be sensible I will discuss this with the couple there and then. Even if they had decided not to give it, I have never known a situation where the couple continued to refuse if there was an indication that giving it would be a good idea.
>Policy throughout all UK health authorities (NHS) is to give routine I/M >dose of vit K in the first hour following delivery. If the parents refuse >I/M, then 3 x oral dose is recommended.>
Actually at the NHS unit where I work policy is to *offer* 3 oral doses, and there are no specific guidelines as to when the 1st dose should be given. I tend (and I am not alone in this) to give it after the first feed, as it seems illogical to give it on a sterile gut.
>I then talk about the fact that globally all babies are born with low levels >of vit K, and all breastfeeding women have low levels of vit K in breastmilk >during the early postnatal period.>
To be pedantic, I would say that babies are born with *less* Vitamin K than adults, rather than low levels of Vitamin K. Babies are different. The parameters of normality are different in many respects between adults and neonates. Babies are a hell of a lot shorter than adults but no-one interprets that as pathological, do they?
That’s not pedantic – that’s correct use of language!
We do have to be careful, and using words like ‘low’ and ‘high’ presuppose a different and contrasting norm – and of course it’s the ‘low’ levels of Vit K in the newborn that are the norm themselves.
It’s rather similar to the way breastmilk and breastfeeding are said to confer health benefits – whereas it’s actually more correct to talk about ‘health risks’ of formula feeding.
I confess, however, that I am careful about the context I am in, and who I am talking to, when discussing the ‘health risks’ of formula.
Heather (breastfeeding counsellor)
I have been asked what UK hospitals do about antibiotic eye drops and Vitamin K. Both these are administered routinely within an hour of birth in the US.
I replied that as far as I know eye drops are never given routinely, and while Vit K is given routinely with parents permission, this is never done straight after birth. Am I right?
“In the US, the American Academy of Pediatrics and the American College of Obstetrics and Gynecology together have established the practices which I previously described as “standard of care.” This is despite the fact that there is no data to back-up the time limit (1 hour). ..What do your pediatricians, neonatologists say? Is there a national policy with respect to vitamin K administration? If the US and Canada are the only ones doing it this way, then I would want to eventually work on changing it.”
Our pediatricians say as long as the baby gets Konakion within 6 hours, it is OK, so I don’t feel that hurried. I know many of my colleagues use the injection to get the baby to cry vigorously (!) but that isn’t my style. At all. I have no idea how the peds. arrived at the 6 hour limit either. It varies from hospital to hospital here. HDN (haemorrhagic disease of the newborn) is something most of us have never seen, as it is almost nonexistent here.
Vitamin K prophylaxis is meant to prevent hemorrhagic disease of the newborn, which doesn’t manifest itself normally in the first day of life, but rather after many days or even weeks. Seems logical to me that the injection could be delayed beyond the first hour after birth. But most people seem to think it gives a baby some magical protection against bleeding from whatever trauma we may have inflicted on it during birth. If this is what is guiding practice, I would suggest that there are many other aspects of that practice which are ripe for evaluation– if not overripe to the point of rottenness!
In my unit all women are given an information sheet about the pros and cons of oral and IM Vit K during the antenatal period (the Trust recommends the use of IM Vit K.) If the parents choose to have Vit K, the 1st dose is usually given in the delivery room. Consent must be given. For oral Vit K, a further 1 or 2 doses (depending on method of feeding) at weekly intervals is given.
A colleague of mine gave methergine to a baby instead of Vit K once. The baby did fine but she nearly had a nervous breakdown. And a new graduate once gave Pitocin to a baby instead of Vit K. Same thing happened.
Vitamn K in my unit is given pretty quickly after birth. In my little tray beside the delivery pack is two syringes already prepared – one has syntometrine for third stage and the other has vitamin K for the baby. Pretty much as sooon as the placenta is delivered we ‘see to’ the baby -give it a midwives newborn examination and vitamin K injection. I would say in nearly all cases vitamin K is given within an hour of birth. However I have not been to the unit since it gained baby friendly status so maybe practice has changed a little.
I am at St Thomas’s, London, and there too our policy is to give oral vit. K (although after an instrumental delivery they strongly reccomend IM)
NHS vitamin K policy varies from Trust to Trust. In Nottingham community and at the maternity unit, intramuscular vitamin K is offered in three lots of oral dose of 0.5mg in 1ml after birth within 24 hours, at 7 days and at 28 days to all nursing babies. Breast milk substitute-fed babies only receive one oral dose after birth. Sometimes some women request intramuscular vit K for term babies(I know of two cases where both mothers were neo-natal nurses). Premature babies are given intramuscular vit k. The 0.5mg in 1ml intramuscular dose is not licensed for oral use so the paed or G.P. has to cover the prescription. I know there is a licensed 2mg oral dose but we do not use this.
I discuss the issue with the parents (but usually the mother) about why vitamin K was introduced in relation to haemorrhagic disease of the newborn. I explain that it is a very rare condition – about 1:10000 term neonates in which bleeding that could lead to the baby’s demise occurs. I discuss why the I.M. vit k locally is not offered as an injection due to that one off piece of research about the childhood link to leukaemia.
It is explained that some women who plan to nurse their babies take vitamin k supplements a few weeks before the due date rather than give vitamin k to the baby. If women want further information I will photocopy the current articles. I acknowledge I haven’t been asked to do this for a while. The maternity unit issues a leaflet about vit k before giving it with mother’s consent. Some women refuse and that is documented and left at that.
Kerri-Anne – NHS Community Midwife.
Personally, I chose not to have Vitamin K injected into my baby at birth, as I did not want him welcomed to the world with an intramuscular injection. Given that the incidence of Haemorrhagic Disease of the Newborn is so very low (approx 1 in 5,000 gets it and 1 in 10,000 dies from it), I decided that if there were some indication that he might be at greater than average risk, eg preemie, or a traumatic birth by forceps, then he would have the injection.
However, the oral preparation seemed hardly worth bothering with, on the grounds that I understand the greatest risk is within the first three days, and it is reportedly hard to get enough oral Vitamin K into the baby in that period to make much difference.
The possible connection between injected Vitamin K and childhood cancers seems like a red herring to me – the purported link was found only in the UK and no correlation occurred elsewhere, which strongly suggests confounding factors. I attended a talk by Michel Odent at which he mentioned that this may by related to parental choice in other matters. In the UK we are free to refuse Vitamin K injections for our babies, as well as any immunisations. Certainly many parents do not realise that they have a choice, but a significant proportion do.
In contrast, Odent said that in some of the other countries studied, parents were not consulted about Vit K injections, and that some or all childhood immunisations were also compulsory or given without parental consultation. He suspected that the sort of parent in the UK who refused routine Vit K injections for their newborn, would also be doing other things differently from the control group. They might well be taking immunisations on a case-by-case basis, refusing some or all. They might well be health-conscious and well-informed, and might be rearing their children on good diets. There might be many other factors… but his suspicion was that refusal of the Vit K injection was a ‘marker’ for these other factors, and was not a direct cause of the increased cancer rate.
I would like to see more details of the stats and studies behind this theory – which countries were involved, and what are their procedures re Vit K injection for example – but it’s certainly food for thought.
> The possible connection between injected Vitamin K and childhood cancers > seems like a red herring to me – the purported link was found only in the UK > and no correlation occurred elsewhere, which strongly suggests confounding > factors.
This is oft-quoted but no other country uses the same preparation of Vitamin K as we do so like was not compared with like. While the link does not seem likely, the preparation used at the time contained, admittedly in very small quantities, a known carcinogen.
The enzyme required to synthesise Vit K is not evident in the gut of the baby until it is three or more months old. Why? Nature doesn’t normally get it this wrong.
I did come across a study which suggested that pollutants in the environment may be contributing to less effective clotting systems, but I don’t believe that this was a contributing factor in the decision to introduce Vit K on a blanket scale by paediatricians. Anyway if there is any weight in the hypothesis, why aren’t we being told more about it?
Do babies need more Vit K than they get naturally?
This is another part of the debate and I accept that there may be very good physiological reasons for why a newborn should not be overdosed on artificial Vitamin K.
Women with reasonable nutrition should probably have the “optimun” amount of vit k. Frye again “Healthy human milk from an unsupplemented mother contains a small amount of vit k”. and I would suggest likely the right amount- but we need the evidence to counteract the utilitarian approach of supplementing babies.
The women we work with are encouraged about skin-to skin and to nurse frequently, but many choose to do otherwise and put their baby elsewhere in a moses basket! And there are issues about poor nutrition and chemical misuse as well.
The Bristol study – Vitamin K injection linked to childhood leukaemia?
I believe that the original Bristol study started by looking at all babies born in Great Britain in one week of April 1970 (total=16,193). 33 developed cancer by 10 years of age. Three children without cancer were chosen as controls for each case.
Compared to the controls: mothers of children with cancer were slightly more likely to: bottlefeed; smoked 5+ cigs daily in pregnancy; used the Pill in the 18 months prior to conception, and had blood group other than A. There were statistically significant relationships between childhood cancers and: antenatal X-rays (including non-abdomen); antenatal smoking; gestation outside 39-41 weeks; `pethidine in labour’; drugs (predominately `vit K’) to neonate. The greater the number of risk factors, the more likely to develop cancer. Only maternal smoking and neonatal drugs remained independently statistically significant (i.e. the pethidine link may be chance).
There were only a small number of cases, but there was some support for findings of others; i.e. childhood cancer was associated with antenatal X-rays, antenatal smoking and pethidine in labour. The vit K link was unexpected and needed more investigation… which they did!
The above is from notes that I made from an article in MIDIRS 1991(1:1), I keep it folded up in the back of my work diary along with some other information about vit K.
In MIDIRS June 1992 (2:2) there is a report on the 2nd Bristol study which looked at babies born in Bristol in 1965 and 1987. The criticisms were that all the data was from one hospital (so there could be other variables relating to the place), and poor records (either missing or method of administration not recorded). They said that the link with vit K (IM) may not be causal but suggest a 1:500 risk, double the normal risk. This article also mentions the risk of a `normal’ baby developing HDN as 1:10,000. This is where it all started from… I could write more but I was on call last night and I need my beauty sleep!!
Some women who plan to nurse their babies take vitamin K supplements a few weeks before the due date rather than give vitamin K to the baby. Could you please tell us what evidence there is to support antenatal supplementation, as I thought it would not be absorbed by the fetus.
I wasn’t suggesting that the woman takes it to supplement the foetus but rather to ensure that her own levels of vit K are optimum in her colostrum for when she commenced nursing the baby – sorry if that wasn’t communicated. It is acknowledged that placental transportation is poor for this element of the clotting mechanism.
Is there any good evidence that the colostrum `contents’ can be manipulated in this way? If it’s thought babies need more vit K than they get, then just don’t separate mothers and babies, also encourage skin-to-skin contact so there are lots of opportunities for small, frequent feeds, and feed unrestrictedly.
I agree completely with you. Women with reasonable nutrition should probably have the ‘optimum’ amount of vit K.
I do believe that there is some odd lack of evidence based-practice and some poor research around vit K.
Anne Frye’s book is my main current source of what I consider to be credible information on the subject (Frye, UDT 1997 p857) her discussion goes on for pages and the quote below is taken out of this if, anybody wants anymore information she has a website and take the debate up with her:
Studies have shown that Vit K deficiency occurs primarily in babies receiving small amounts of breast milk or even small amounts of formula during the first days of life. Nursing should begin at birth and continue every two hours [I personally have a problem with this amount of prescriptive advice] or more often on demand. Be sure mothers understand that although the volume of colostrum is not great, it is the perfect food for their babies during the first few days and is important to prevent classical VKBD (Vitamin K Bleeding Disorder). If the mother supplements her diet with vit K, levels in breast milk begin to rise and are dramatically increased by 12 hours (Haroon, 1982). This was the first study to demonstrate such a response and further studies have conformed this finding (Sutor & Hathaway, 1994)
I don’t know if this is good evidence not having checked out the original papers but it is a contribution to the picture.
I’d much rather the maternal metabolism deliver the necessary amount of vit K in breast milk than the NHS utilitarian approach of vit K supplements for all babies. However, there still may be individual babies who will need a supplement, there are documented case histories of HDN.
I recently researched HDN following an enquiry by a mother, and discovered that to my surprise the rate of haemorrhagiic disease of the newborn is about 1 : 1000 , although the rate of the disease which is severe enough to lead to fetal demise is the 1: 10,000 we were all taught in our midwifery training.
There has recently been a story in my local paper about a so called scandal at our local hospital regarding vitamin K to babies and risk of cancer. It seems that ‘most’ hospitals are giving an unlicensed product to parents and also that they are not informing parents of any possible dangers.
I am not a health professional but I understand that it is not uncommon to give unlicensed products like this. How should mums feel about this? What is the point of having a license if you can give the stuff to patients without one? .. Mums want to have confidence in their decisions – if we know there are risks we can weigh them up against the risks of not taking something/benefits of taking it and make an informed decision. But when a product is said to be unlicensed, it immediately makes the risks of consenting to it seem much much greater..
Orakay, one oral version of vit K, isn’t licensed in the UK. We have been using it but parents are aware of this and sign a consent form. The reason for it not being licensed is that it’s not worth it for drug companies. It’s very unusual for paediatric drugs to have been trialled on children; the majority of drugs used on children have been tested on adults and the assumption is then made that they could be used on children. However that decision is made by the consultant caring for that child and they then take on liability, which is what our paeds did at our unit.
The initial reason for offering oral vit K was a study in Bristol that appeared to link injectable vit K with childhood leukaemia. This study has since been ‘disproved’ in that the findings haven’t been reproducable! However as I don’t know who paid for the research to be done I can’t say if it’s particularly correct.
We always use Konakion MM Paediatric, which is licensed for use in the UK and may be given either I/M or orally. The woman’s GP does the prescription, and the woman then collects and holds it until needed. Actually, at least half of our women choose not to give the baby vit K anyway.
Do you know if the IM preparation is stabalized in the same substance and is equally absorbed if ingested, as a made for oral admin preparation?
It was my undestanding that IM Vit K should not be given orally since the drug is not made for oral use. I think the manufacturer is concerned that IM preparations will not work orally.
The Vit K we use says IM and oral use. We give 1st dose in 4 hrs, 2nd dose at 7 days, 3rd dose monthly. If mums are breastfeeding and chose oral administration then the babe gets a dose monthly until she stops breastfeeding.
Anyway this whole Vit K issue is a bit of a worry. So many units do different things, so how can a woman know what is right? Logically I would think if we knew Vit K was beneficial we would all give it the same way.
I think the way the unit I work in prescribes Vit K for breastfeeding mothers conflicts with the advice that we give about breast is best but we will just add this Vit K to your baby since we think breastmilk doesn’t have enough!!!
Absolutely. The studies showing ‘inadequate’ Vit K (or rather, babies apparently at risk of HD being more likely to be breastfed) were carried out at a time when babies were more often separated from their mothers and feeds were timed and scheduled.
My last breastfed baby received the IM prep. as oral, and had really bad colic for the rest of the night. The only time, I hasten to add. One of my colleagues had given it as an error, and when I checked it out with the pharmacist, they confirmed that the base that held the VitK was the probable cause of her discomfort. She is a thriving 2 year old, with no long term effects.
Oral VitK is not available where I live (WA, USA) so if women want oral (or some, none) that is their informed choice for a healthy birth and baby. What we do is give 3 doses of the Im, oral via a syringe 1st within 24hrs and within 5 days, 3rd within 6 weeks.
After much lobbying by women, midwives and other Health professionals here in New Zealand, the prepared neonatal oral dose 2mg/0.2ml times three doses at the intervals of birth, 5 days and six weeks has been gazetted for introduction by Roche at the end of October by our Ministry of Health. It appears from reading the literature that as long as the three oral divided doses are given that it is as effective as the IM route. This decision has been a long time coming and very welcomed. I have very seldom in the past 10yrs given the IM dose orally as most woman and their families seldom use it as their first choice as the route of administration. I feel the phenyol and caster oil that is in the IM preparation to keep it stable is deterimental to the initiation of breast-feeding. Have a taste of the IM stuff yourself. Believe me the taste remains with you for sometime.
Hate to say this, but so does the taste of the oral dose by Roche. We give only give a small amount of the recommended dose – 0.1ml at one unit, or 0.05ml t’other unit’s prescription – but it still tastes disgusting!
Readers might be interested to know that of the two Konakion preparations produced by Roche Pharmaceuticals, one is suitable for vegetarian babies and one is not. The details are as follows:
Konakion l mg/0.5 ml ampoule, for intra-muscular administration, is an animal free product. However, Konakion MM Paediatric (phytomenadione) 2 mg/0.2 m1 ampoule, for oral administration, has the gall bladders of cattle used as part of its production, and therefore might not be acceptable for parents of vegetarian babies.
In response to a request for information from Roche on this subject, they state that glycocholic acid, which is a component of the orally administered Konakion, is synthesised using cholic acid which is extracted from the gall bladders of cattle. In the preparation for IM administration however, glycocholic acid is not used and `therefore can be used as a suitable animal-free product if required’.
Midwives might find this information helpful if offering vitamin K to parents for their babies.
Thought you might be interested in the suggestion of a good reason for low vitamin K levels:
Observations on vitamin K deficiency in the fetus and newborn: has nature made a mistake?
AUTHORS: Israels LG; Israels ED
AUTHOR AFFILIATION: Department of Medicine, University of Manitoba,
Manitoba Institute of Cell Biology, Winnipeg, Canada.
SOURCE: Semin Thromb Hemost 1995;21(4):357-63
CITATION IDS: PMID: 8747698 UI: 96357538
ABSTRACT: The microsomal mixed function oxidase system metabolizes xenobiotics (Phase I) to products that, if not activated and conjugated for excretion (Phase II), are capable of forming conjugates with cellular macromolecules, including DNA, resulting in toxic, mutagenic, or carcinogenic events. Benzo(a)pyrene (BP), a polycyclic aromatic hydrocarbon, is a model carcinogen for this system. Vitamin K1 (phylloquinone) is a regulator of BP metabolism. These studies demonstrate that K1 is capable of increasing Phase I metabolism and decreasing glutathione transferase activity (Phase II) in chick embryo liver; that deprivation of K1 reduces BP/DNA adducts in mouse liver and reduces tumor formation in mice given intraperitoneal BP; and that K1 supplementation increases BP induced tumor formation in mice. However, epidemiologic studies indicate that children of mothers who smoke during pregnancy may not be at increased risk of cancer. It is known that the placentas from these pregnancies exhibit markedly increased levels of arylhydrocarbon hydroxylase induced by the polycyclic aromatic hydrocarbons in tobacco smoke, but there is no corresponding increase in this enzyme activity in the fetus in such pregnancies. We suggest that the low vitamin K level is a secondary protective mechanism for xenobiotics, such as BP, that may escape the primary placental screen. The recently described role of vitamin K-dependent Gla protein as ligands for receptor tyrosine kinases, also establishes K as a link in cell growth and transformation. It is proposed that the small total body pool of K1 in the adult, which is sufficient only to meet continuing needs, and the even smaller pool in the fetus are protective. This protective effect of low K1 levels is particularly important in the presence of the high mitotic rates and rapid cell turnover in the avian embryo and mammalian fetus.
Midwifery Today E-News (Vol 2 Issue 19) is a special on Factor V Leiden (FVL) – a genetic condition which increases the chances of blood clots developing. Depending on the area, between 3% and 10% of caucasian people carry the FVL gene; no stats are given for people from other ethnic groups, and it is implied that it is a caucasian anomaly. The baby of someone carrying FVL has a 50% chance of carrying it too, and the author speculates that routine vitamin K administration could be dangerous for these babies. Interesting thought – and how many areas routinely test women for the condition? If they don’t, routine vitamin K adminitration could be putting their babies at risk.
I’ve copied an excerpt below:
o=o=o=o=o=o=o MIDWIFERY TODAY E-NEWS :a publication of Midwifery Today, Inc. (www.midwiferytoday.com)
Volume 2 Issue 19 May 12, 2000
Factor V Leiden Code 940
All the following information on Factor V Leiden has been prepared by Jennifer Rosenberg, CD (DONA).
Pregnancy, Clotting, and Factor V Leiden: An Overview
The past 10 years have brought new understanding of and explanations why some women clot on birth control pills and during pregnancy. Research into genetic origins of disease has uncovered many coagulopathies, some of them surprisingly common. The most common is Factor V Leiden, also known as Activated Protein C Resistance, which carries a 3-10 times greater risk of clot when someone has one copy of the gene and 30-140 times greater risk of clotting for someone with two copies.
Between 3% and 10% of Caucasian people are heterozygous for Factor V Leiden, and a much smaller percentage are homozygous. In Sweden the rate of heterozygous mutation may be as high as 15% in some areas, while in other parts of the world and among other races only a fraction of a percent of the population may have it. It is thought that the original mutation occurred as much as 20,000-30,000 years ago in a single individual.
Women with Factor V Leiden (FVL) have a substantially increased risk of clotting in pregnancy (and on estrogen containing birth control pills or hormone replacement) in the form of DVT (deep vein thrombosis, sometimes known as “milk leg”) and pulmonary embolism. They also have an increased risk of preeclampsia, as well as miscarriage and stillbirth due to clotting in the placenta, umbilical cord, or the fetus (fetal clotting may depend on whether the baby has inherited the gene). Note that many, many of these women go through one or more pregnancies with no difficulties, while others may miscarry over and over again, and still others may develop clots within weeks of becoming pregnant.
… Remember that approximately one in twenty of the women you serve will have FVL. Approximately one in a hundred of women with FVL (estimates vary radically from a 1% thrombosis rate (4) to a 25% thrombosis rate (my hemotologist) will have a serious DVT during pregnancy…
FVL is inherited. This means that for every pregnant woman who has FVL, the child she carries has at least a 50% chance of inheriting the disease (more if the father also has it). ..
Vitamin K encourages clotting, and thus there is some concern among parents with FVL about giving their newborns the prophylactic vitamin K bolus. At the very least such treatment should NOT occur immediately after birth, when hormone levels are still up, in my opinion as a parent. And it may be advisable (though research has not been done!) to do the quick screening test for FVL (not the genetic test; this test simply checks to see how resistant clots are to activated protein C) prior to giving the infant vitamin K later. Perhaps testing cord blood for APC resistance immediately after birth and only giving negative babies vitamin K would be reasonable. Another approach would be to delay the vitamin K shot for 6-12 hours if not longer, to allow hormone levels to drop. I am aware of one family that feels their baby’s death was caused by the vitamin K shot. Although the story is completely anecdotal, it echoes fears I had with my own daughter.
(End of excerpt from Midwifery Today E-news. Please visit the Midwifery Today website at www.midwiferytoday.com.)
For info on Vitamin K the MIDIRS midwifery digest is unparallelled. They also have a collection of references on it. Most recent info in MIDIRS is in the 1998 issues, and not much has happened since then in the way of research. There is far too much to do it justice in an on-line discussion here.
AIMS Occasional Paper – Vitamin K in relation to haemorrhagic disease of the newborn, by Joan Donley, OBE It is available from the Publications Secretary, 2 Bacon Lane, Hayling Island, Hants, PO11 ODN, costs £2.50 incl. p&p.
Vitamin K discussions on USA Midwife Archives:
Midwifery Today E-news article on Vitamin K:
AH updated 5 October 2000