Vitamin K Deficiency in the Setting of Blenderized Tube Feeding Regimen in a Teenager: A Case Report

Abstract

Vitamin K acts a cofactor for the gamma-carboxylation of several proteins in the coagulation cascade. The clinical spectrum of vitamin K deficiency (VKD) can be asymptomatic to a significant bleeding. VKD is classically seen in newborns. However, this can manifest later in patients with risks such as sub-optimal nutrition, fat malabsorption, medications including antibiotics. A 17-year-old male with spinal muscular atrophy (SMA) Type 1, tracheostomy with ventilator dependent, gastrostomy tube feeding was seen by the gastroenterologist following treatment for small intestinal bacterial overgrowth (SIBO). Investigations showed coagulopathy following which he was transferred to the Pediatric ICU. Labs revealed prothrombin time (PT) 114 s [Normal 9.4–12.5 s], INR (International normalized ratio) 12.6 [Normal < 1.1] and partial thromboplastin time (PTT) 90 s [Normal 25.1–36.5 s]. Mixing studies and coagulation assays were consistent with VKD (low Factor VII and Factor IX with normal Factor V). His home blenderized feeding regimen met the caloric requirement but not the adequate intake (AI) values for vitamin K and other minerals. He received intravenous vitamin K (phytonadione) for five consecutive days with resolution of the coagulopathy (PT 13.2 s, PTT 37.1 s, INR 1.2). The patient was discharged on enteral vitamin K and additional supplements following dietary review by a nutritionist. Clinicians should be cognizant of VKD in patients on blenderized tube feeds which may not meet the adequate intake (AI) goals. In patients who are not receiving nutritionally complete formulas or receiving inadequate volumes, it is important to monitor macro and micronutrients.

Keywords:

• Coagulopathy
• pediatrics
• tube feeding
• vitamin K deficiency

Acknowledgements

The authors would like to thank Ashley Kiser RD for her assistance.

Author’s contributions

R Lamsal and A Malkani contributed to the conception of the research; N Khan contributed to the acquisition of the data; N Khan and M Taimur equally contributed to the interpretation of the data and drafted the manuscript. All authors critically revised the manuscript, agree to be fully accountable for ensuring the integrity and accuracy of the work, and read and approved the final manuscript.

Disclosure statement

No potential conflict of interest was reported by the authors.

IRB approval

The need for approval was waived by the Ballad Health System institutional review board as it did not meet the definition of human subject research (IRB 00003204).

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Additional information

Notes on contributors

N. Khan

Natasha Khan, MD is currently a pediatric resident at East Tennessee State University, Tennessee. Her research interests include neonatal resuscitation and pediatric global infectious diseases.

M. Taimur

Muhammad Taimur, MBBS is a graduate of Dow University of Health Sciences and is currently pursuing a U.S. residency match application. His research interests focus on nutritional deficiency disorders of the adult and pediatric populations in developing countries.

A. Malkani

Anjali Malkani, MD is a professor of pediatrics and division head of pediatric gastroenterology at East Tennessee State University. She obtained her medical degree from Calcutta university in India and did her pediatrics residency at The University of South Florida. She completed her fellowship in pediatric Gastroenterology, Hepatology and Nutrition at Stanford university. Her clinical interests include general pediatric gastroenterology with a focus on nutrition and feeding disorders in children.

R. Lamsal

Riwaaj Lamsal, MD completed his pediatric critical care fellowship at University of Minnesota. He is currently an assistant professor of pediatrics at East Tennessee State University, Tennessee. His research interests include mechanical ventilation, pediatric metabolic disorders, and enteral nutrition in critically ill children.