History:

A 38 week gestational age baby was born outside of a hospital to a 17-year-old who had a history of intravenous drug use and who smoked 1 pack of cigarettes per day. The baby weighed 2000 gm at birth at 38 weeks. The baby was brought to a hospital emergency room at 5 days following delivery because of marked oozing of blood from the umbilical cord stump. Ecchymoses were noted over the abdomen and scalp as well.

The child was fed only milk in the first year of life. At age one the baby was brought to the emergency room by the grandmother who had noted a hot, swollen area on the right thigh surrounding a 2 cm laceration that was still not healed three weeks after it had occurred. The baby was also found to be anemic.

Answers:

1. What explains the low birth weight (<2500 gm at term)?

The maternal history of smoking is the most likely factor. Poor nutrition plays a role as well, which is common in persons abusing drugs.

2. What vitamin is typically given to newborns to prevent the problem seen here soon after birth?

Vitamin K deficiency explains the findings. The blood coagulation factors (II, VII, IX, and X) made in the liver require vitamin K as a cofactor in carboxylation of glutamate. A deficiency leads to a coagulopathy with abnormal bleeding, so called "hemorrhagic disease of the newborn". The most serious consequence of this could be intracranial hemorrhage. Once the bacterial flora of the GI tract are established, there is endogenous production of vitamin K to produce most of the daily requirement.

3. What is a contributing factor for the cellulitis?

Vitamin C deficiency is present. Vitamin C is needed to hydroxylate procollagen in order for form stable connective tissues. A deficiency of vitamin C is called scurvy. Wound healing requires adequate connective tissue formation with collagen.

4. How do you explain the anemia?

Iron deficiency along with the Vitamin C deficiency are present. A deficiency of vitamin C results in poorly constituted capillaries and venules from which bleeding can occur. The bone matrix has deficient type 1 collagen with scurvy, leading to skeletal deformities in children as well. The world's most common nutritional deficiency is iron. Iron is needed to form the heme in hemoglobin. Children need iron as they grow and need red blood cells.