Pediatrics 2014 Sahni 497 503

Neonatal Vitamin K Refusal and Nonimmunization

WHATS KNOWN ON THIS SUBJECT: Vitamin K prophylaxis at birthis an effective intervention for preventing vitamin K deciencybleeding.

WHAT THIS STUDY ADDS: Refusal of vitamin K is not common, butthose who refuse are more likely to have a birth attended bya midwife, and deliver at home or in a birth center. They are alsoless likely to immunize their child.

abstractBACKGROUND: Neonatal Vitamin K prophylaxis is an effective interven-tion for reducing vitamin K deciency bleeding. A recently publishedreport of parental refusal of vitamin K prompted an investigation ofthe prevalence and characteristics of this group, and exploration ofwhether these same parents were likely to subsequently refuse immu-nization for their children.

METHODS: We conducted a retrospective population-based cohortstudy of all infants born in Alberta between 2006 and 2012 by usinglinkage of administrative health data. Risk factors for vitamin Krefusal were determined by using Poisson regression. The associationbetween vitamin K refusal and nonimmunization was assessed usingrelative risk.

RESULTS: Among the 282 378 children in the cohort, 99.7% receivedvitamin K and 0.3% declined. Midwife-assisted deliveries were morelikely to be associated with vitamin K refusal compared withphysician-attended delivery (risk ratio 8.4, 95% condence interval[CI] 6.511.0). Planned home delivery (risk ratio 4.9, CI 3.86.4) ordelivery in a birth center (risk ratio 3.6, CI 2.35.6) were more likely toresult in decline of vitamin K compared with hospital delivery. VitaminK refusal was associated with a 14.6 (CI 13.915.3) higher relative riskof having no recommended childhood vaccines at 15 months.

CONCLUSIONS: This is the rst population-based study to characterizeparents who are likely to decline vitamin K for their infants and whosechildren are likely to be unimmunized. These ndings enable earlieridentication of high-risk parents and provide an opportunity toenact strategies to increase uptake of vitamin K and childhoodimmunizations. Pediatrics 2014;134:497503

AUTHORS: Vanita Sahni, MHSc,a Florence Y. Lai, MPhil,a

and Shannon E. MacDonald, PhDb,c

aAlberta Health Surveillance and Assessment, Edmonton, Alberta,Canada; bDepartment of Pediatrics, University of Calgary,Calgary, Alberta, Canada; and cFaculty of Nursing, University ofAlberta, Edmonton, Alberta, Canada

KEY WORDSvitamin K, immunization, health education

ABBREVIATIONSCIcondence intervalDTaP-IPV-Hibdiphtheria, tetanus, pertussis, polio, Haemophilusinuenza type b vaccineIMintramuscularMMRmeasles, mumps, and rubella vaccineMMWRMorbidity and Mortality Weekly ReportNOBnotice of birthVKDBvitamin K deciency bleeding

Ms Sahni conceptualized and designed the study and drafted theinitial manuscript; Ms Lai conceptualized and designed thestudy, carried out the analysis, and reviewed and revised themanuscript; Dr MacDonald conceptualized and designed thestudy and reviewed and revised the manuscript; and all authorsapproved the nal manuscript as submitted.

www.pediatrics.org/cgi/doi/10.1542/peds.2014-1092

doi:10.1542/peds.2014-1092

Accepted for publication Jun 11, 2014

Address correspondence to Shannon MacDonald, PhD,Department of Pediatrics, University of Calgary, 2888 Shaganappi TrailNW, Calgary, Alberta, T3B 6A8, Canada. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright 2014 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno nancial relationships relevant to this article to disclose.

FUNDING: Dr MacDonald was supported by a fellowship fromthe Canadian Institutes of Health Research and a postdoctoralclinician fellowship from Alberta InnovatesHealth Solutions.

POTENTIAL CONFLICT OF INTEREST: The authors have indicatedthey have no potential conicts of interest to disclose.

PEDIATRICS Volume 134, Number 3, September 2014 497

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VitaminKprophylaxis is aneffectiveandaccepted intervention for preventingvitamin K deciency bleeding (VKDB),ararebleedingdisorder inearly infancythat can result in long-term neurologicdecits and death.1,2 Neonatal vitamin Kis recommended by the AmericanAcademy of Pediatrics3 and the CanadianPediatric Society.4 In Canada, vitamin Kis typically administered through asingle-dose intramuscular (IM) injec-tion at birth, but parents can opt fora multidose oral form administered atbirth and over the rst few weeks oflife.

A recentMorbidity and Mortality WeeklyReport (MMWR) documented a clus-ter of 4 cases of VKDB in infants inTennessee, all among infants whoseparents had refused vitamin K pro-phylaxis.5 This report prompted an in-vestigation of vitamin K refusal in ourjurisdiction. As the reasons for vitaminK refusal in the MMWR report includedconcerns about the safety of the med-ication, we hypothesized that the pro-le of women refusing vitamin K maybe very similar to that of a subset ofvaccine-hesitant parents. If true, re-fusal of vitamin K would allow for earlyidentication of this group for targetedsupports and education. The purposeof this study was to determine theprevalence of vitamin K refusal, de-scribe the characteristics of parentsrefusing vitamin K, and investigate thehypothesis that parents who refusevitamin K for their newborns are alsolikely to not immunize their child.

METHODS

Setting

This study was conducted in the prov-ince of Alberta, Canada, which has anannual birth cohort of 50 000 infants.Canada has a publically funded healthcare system that is administered by theindividual provinces. All residents inAlberta are required to register with

the provincial Health Care InsurancePlan, which covers the cost of prenatalcare, delivery, postpartum care, andchildhood immunizations according tothe schedule determined by the Minis-try of Health. Residents have a choice ofhealth care provider and expectantmothers with low-risk pregnancies canchoose to have an obstetrician, familydoctor, or midwife deliver their infant;high-risk pregnancies are delivered byobstetricians. Midwives offer their cli-ents a choice of delivery location, pro-viding services in a hospital, birthcenter, or at home; physicians routinelydeliver in hospitals. Both birth centersand home births have similar limitedavailability of emergency equipment,and clients must be transferred toa hospital should complications arise.Midwives are a relatively new careprovider in the province; they havebeen registered since 1992 and theirservices publically funded since 2009.6

In 2012, 1600 (3%) live births inAlberta were delivered by midwives(unpublished Ministry of Health data).

Study Design and Data Sources

We analyzed a population-based cohortof all live births in Alberta between 2006and 2012 for whom information on vita-min K administration at birth was avail-able (n = 282 378 or 81% of live births inAlberta during the period). Neonatal vi-tamin K administration is documentedon the Notice of Birth (NOB), which cap-tures maternal and infant informationon all births that occur in Alberta. TheNOB form is completed by health carestaff at the birth facilities based on pa-tient charts. Vitamin K prophylaxis isrecorded as intramuscular, oral, orparent declined. Additional data ob-tained from the NOB database includedsite of delivery, primary attendant atbirth, maternal age, gestational age, andsmoking during pregnancy. We determin-istically linked individual-level NOB datato other administrative health databases

by using personal health numbers, whichare unique individual identiers assignedat the time of registration to the AlbertaHealth Care Insurance Plan. Informationon cesarean delivery, administration ofepidural during labor, and same or nextday admission to the NICU was extractedfrom the Hospital Discharge AbstractDatabase.

Data on immunization uptake wasobtained from the provincial immuni-zation repository known as ImmARI.ImmARI captures individual-level dataon all childhood immunizations ad-ministered since 2006, except for FirstNations (the largest aboriginal group inCanada) children living on reserve. Welinked immunization recordsof all nonFirst Nations children in our study co-hort who were born between 2006 and2011 and remained Alberta residentsas of 15 months of age. We omittedchildren born in 2012 from this analy-sis, as some of them had not yetreached 15 months when the analysiswas conducted. The resultant cohortincluded 214 061 children. According tothe recommended childhood immuni-zation schedule, a child 15 months ofage would have 3 doses each of DTaP-IPV-Hib (diphtheria, tetanus, pertussis,polio, Haemophilus inuenza type b),meningococcal and pneumococcal con-jugate vaccines, and 1 dose each ofMMR (measles, mumps, rubella) andvaricella vaccines. Assessment of cov-erage at 15 months of age permitteda 3-month grace period from the timethe 12-month immunizations were sched-uled. Unimmunized children were de-ned as those who received no doses ofthe recommended vaccines.

Statistical Analysis

We determined the uptake of vitamin Kprophylaxis in Alberta from 2006 to2012, and evaluated trends in parentalrefusal rates during the period using theCochran-Armitage trend test.Weusedx2

test to examine the association between

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vitamin K refusal and maternal and in-fant characteristics. We estimated therisk ratios of vitamin K refusal by usingPoisson regression analysis.

For the 2006 to 2011 nonFirst Nationsbirth cohort, we calculated the pro-portion of children who were un-immunized at 15 months. Relative riskand 95% condence intervals (CIs)were computed to examine the asso-ciation between vitamin K refusal andnonimmunization. All data manage-ment and statistical analyses werecarried out using SAS version 9.3 (SASInstitute, Inc, Cary, NC). A P value ,.05was considered statistically signi-cant. Ethical consent for this study wasobtained from the University of AlbertaHealth Research Ethics Board.

RESULTS

Uptake of Vitamin K

The uptake of intramuscular and oralvitamin K prophylaxis in this cohort was99.3% and 0.4%, respectively (Table 1).Only 0.3% of live births did not receiveany vitamin K prophylaxis because ofparental refusal. The refusal rate showeda small but statistically signicant an-nual increase over the study period,from 0.21% in 2006 to 0.39% in 2012(P , .001).

Factors Associated With Vitamin KRefusal

Table 2 presents the characteristics ofinfants and their parents who declined

vitamin K prophylaxis in Alberta. Therewere signicant differences in the up-take of the prophylaxis among birthsites (P , .001) and professionalgroups attending the delivery (P ,.001). Planned home births had a re-fusal rate of 14.5%, and births in birthcenters had a refusal rate of 10.7%; incontrast, births in hospitals had a re-fusal rate of 0.2%. Among infants de-livered by midwives, 6.8% of parentsdeclined vitamin K prophylaxis; thiswas higher than those delivered byphysicians (0.2%). In addition, vitaminK refusal rates were higher in older,nonFirst Nations and nonsmokingmothers. Mothers who had a vaginaldelivery without the use of epiduralduring labor had a refusal rate (0.6%)that was higher than mothers who hadused epidural for vaginal delivery(0.1%) or mothers who had a cesareandelivery (0.2%). Infants who were bornpreterm (,37 weeks) and requiredadmission to the NICU had a slightlyhigher refusal rate at 0.4%, comparedwith 0.3% for generally healthy terminfants not requiring NICU admission.

The multivariable Poisson regressionanalyses (Table 3) showed parents whodeclined vitamin K prophylaxis for theirnewborns were 8.4 (95% CI 6.511.0)times more likely to have a midwifedeliver their infants compared witha physician. They were also 4.9 (95% CI3.86.4) times more likely to havea planned home birth and 3.6 (95% CI2.35.6) times more likely to give birthin a birth center compared with a hos-

pital. They were also more likely to benonFirst Nations, nonsmoking, andhave had a vaginal delivery without theuse of epidural. Parents of preterminfants who required NICU admissionwere more likely to decline vitamin K.

Association Between Vitamin KRefusal and Nonimmunization

Table 4 shows the nonimmunizationrates for children receiving and notreceiving vitamin K prophylaxis. ForDTaP-IPV-Hib, meningococcal conjugateand pneumococcal conjugate, whichare scheduled to have 3 doses by 12months of age, the nonimmunizationrates as of 15 months were consis-tently 5% in those who received thevitamin K prophylaxis (either injectionor oral), but 74% to 75% in those whodid not receive vitamin K prophylaxis.For MMR and varicella vaccines, whichare scheduled to have 1 dose at 12months, 18.7% and 20.4%, respectively,of those who received vitamin K pro-phylaxis were not immunized as of 15months; in comparison, 82.1% and85.0%, respectively, were not immu-nized in those refusing the prophylaxis.Overall, the risk of being completelyunimmunized with any of these sched-uled childhood immunizations (DTaP-IPV-Hib, meningococcal and pneumococ-cal conjugates, MMR, and varicella) at15 months was 14.6 (95% CI 13.915.3)times higher in those who declinedvitamin K, compared with those re-ceiving the prophylaxis.

DISCUSSION

This study builds on previous researchof vitamin K uptake through use ofpopulation-based data. Our ndings arereassuring in that the overall uptake ofvitaminK in this cohortwasveryhighandthe prophylaxis continues to be a wide-spread public health success. However,the small but continuous increase inrefusal of vitamin K is cause for concern.

TABLE 1 Uptake and Route of Neonatal Vitamin K Prophylaxis in Alberta, 2006 to 2012

Year Intramuscular Oral Decline

n % n % n %

2006 37 931 99.39 149 0.39 82 0.212007 38 612 99.25 193 0.50 97 0.252008 42 567 99.25 190 0.44 133 0.312009 39 414 99.26 153 0.39 141 0.362010 37 718 99.31 112 0.29 150 0.392011 42 350 99.25 185 0.43 137 0.322012 41 754 99.26 144 0.34 166 0.39Total (20062012) 280 346 99.28 1126 0.40 906 0.32

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Our data did not allow us to determinethereasonswhyparentsweredecliningvitamin K prophylaxis for their new-borns. A possible reason is a lack of/incomplete knowledge of the risksand benets of the prophylaxis. Ourstudyshowedaconsiderabledifferencein the uptake of vitamin K betweenbirthsattendedbyphysiciansand thoseby midwives, even when adjusted forother confounding factors. A recentsurvey of medical and midwifery atti-tudes toward vitamin K in New Zealandfound that all doctors, but only half of

midwives, believed that all infantsshould receive vitamin K.7 Some mid-wifery literature suggests that vitaminK may not be necessary for all infants.8,9

The perspective or attitude of the healthcare providers could inuence the de-cision of the parents. It is possible thatinformation presented to midwiferyclients on the risks and benets ofvitamin K reects the controversy inthe midwifery literature. This is consis-tent with the MMWR report that foundparental knowledge about late VKDBwas absent or incomplete, suggesting

that parental decisions were not wellinformed.5

Factors such as choice of health careprovider and place of birth may reectpersonal ideologies and growing con-cerns about the overmedicalization ofbirth and a preference for a naturalbirth. Our study showed that motherswhorefused vitaminKprophylaxisweremore likely to choose a planned birth athome or at a birth center and anepidural-free vaginal delivery. Thisnding is consistent with the study byKhambalia et al.10

It is possible that some parents declinevitamin K prophylaxis because of safetyconcerns. In the 1990s, 2 studies byGolding et al11,12 suggested an increasedlikelihood of childhood cancer with vi-tamin K intramuscular injection. Al-though the ndings have been refutedsubsequently inmultiple publications,1315

the legacy of doubt around the in-jection lingers. This is reminiscent ofsimilar legacies of immunization stud-ies that have been clearly refuted, suchas the purported link between MMRvaccine and autism.16

The nding that women who refuse vi-taminKaremore likely tohavea deliveryattended by a midwife highlights op-portunities to improve uptake. First, phy-sicians providing preconception careto women intending to seek midwiferycare should be aware of the need toprovide information about vitamin K.Second, midwives should be engaged,for example by providing guidancedocumentation on VKDB and vitamin Kprophylaxis. There is reason to believethatmidwiveswouldbe receptive to this;a recent survey found 95% of midwivesfelt their rolewas important inprovidingeducation/information on vitamin K,compared with 65% for pediatriciansand 39% of obstetricians.7 Women whohave a midwife delivery typically alsohave received midwifery prenatal care,with the advantage that midwives oftencan spend a great deal of timewith their

TABLE 2 Characteristics of Infants and Their Mothers Who Accepted and Declined Vitamin KProphylaxis in Alberta, 2006 to 2012

Characteristics n IM/OralVitamin K,a n

(%) DeclinedVitamin K, n

(%) P Value

Mothers age, y ,.001,24 61 818 61 683 (99.78) 135 (0.22)2534 175 736 175 137 (99.66) 599 (0.34)35+ 44 824 44 652 (99.62) 172 (0.38)

First-time delivery ,.001No 161 547 160 963 (99.64) 584 (0.36)Yes 120 831 120 509 (99.73) 322 (0.27)

First Nationsb ,.001No 261 496 260 612 (99.66) 884 (0.34)Yes 20 882 20 860 (99.89) 22 (0.11)

Site of birth ,.001Hospital 280 055 279 407 (99.77) 648 (0.23)Birth center 224 200 (89.29) 24 (10.71)Planned home birth 1486 1270 (85.46) 216 (14.54)Othersc 613 595 (97.06) 18 (2.94)

Primary attendant at birth ,.001Physician 272 754 272 212 (99.80) 542 (0.20)Midwife 4699 4381 (93.23) 318 (6.77)Nurse and others 3090 3046 (98.58) 44 (1.42)

Delivery ,.001Vaginal delivery, no

epidural101 329 100 674 (99.35) 655 (0.65)

Vaginal delivery withepidural

106 565 106 446 (99.89) 119 (0.11)

Cesarean delivery 74 484 74 352 (99.82) 132 (0.18)Infant health status at birthd ,.001

Term, no NICU admission 249 059 248 236 (99.67) 823 (0.33)Term with NICU admission 17 740 17 707 (99.81) 33 (0.19)Preterm, no NICU

admission8571 8552 (99.78) 19 (0.22)

Preterm with NICUadmission

7002 6971 (99.56) 31 (0.44)

Smoking during pregnancy ,.001No 223 631 222 799 (99.63) 832 (0.37)Yes 48 003 47 954 (99.90) 49 (0.10)

Missing data: primary attendant at birth (n = 1835, 0.6%), infant health (n = 6, 0.002%), and maternal smoking(n = 10 744, 3.8%).a The small number of infants receiving oral vitamin K (n = 1126) was combined with those receiving IM vitamin K for thisanalysis.b First Nations: the largest aboriginal group in Canada.c Others: primarily unplanned home births, also births occurring en route to hospital (eg, in vehicle).d Infant health status: preterm birth (gestational age ,37 wk); term ($37 wk); NICU admission.


clients providing information, as well asanswering concerns and misconcep-tions about the prophylaxis.

We hypothesized that the characteristicsof parents who refuse vitamin K may besimilar to that of a subset of vaccine-hesitant parents. This group of parentsoften shares a particular worldview ofhealth that includes a preference fornatural health remedies and questionsthe standard recommended practices ofestablished medical authorities.17 Theyare often actively engaged in information-

seeking and decision-making aroundthe health of their child, by using theInternet and alternative health careproviders as trusted sources of in-formation.17,18 In terms of immunization,this may be expressed by concernsabout the necessity, effectiveness, andsafety of vaccines.19,20 Our results con-rm the hypothesis that parents whorefused vitamin K were also more likelyto have unimmunized children.

A previous survey by Cassell et al21 onthe factors associated with MMR re-

jection noted that MMR noncompliancewas associated with declining vitaminK. Until now, this nding has not beenexplored further. To the best of ourknowledge, this is the rst study thatused a large population-based cohortto study the association between vita-min K refusal and nonimmunization.

Our nding of vitamin K refusal asa strong predictor of subsequent child-hood nonimmunization is important be-cause it allows the opportunity for publichealth departments and health careproviders to identify a subset of parentswho are likely to refuse or delay immu-nization for their child, and provide tar-geted support and education about thebenets and risks of immunization ear-lier thanwouldtypicallyoccur.Therehavebeen recent efforts to develop tools toidentify vaccine-hesitant parents basedon assessment of their knowledge, atti-tudes, and beliefs, but the vaccine hesi-tancy was assessed only once the childwas overdue for vaccines.22,23 Our ndingsuggests the possibility of early identi-cation and intervention starting at birth,a time when parents may be most re-ceptive to health information.24,25 Strate-gies might include anticipatory guidancethrough postpartum home visits by apublic health nurse, instead of wait-ing for the infants rst encounterwith the medical system or until therst immunization is missed. Anotherstrategy is to engage the midwife to pro-mote immunization, as women choosinga midwife delivery continue to receivemidwifery care until 6 weeks afterdelivery.

TABLE 3 Multivariable Poisson Regression Analysis of Risk Factors for Refusal of Vitamin KProphylaxis in Alberta, 2006 to 2012

Characteristics Adjusted Risk Ratioa (95% CI) P Value

Mothers age, y,24 1.02 (0.841.25) .8222534 1.00 35+ 1.07 (0.911.27) .419

First-time delivery 0.99 (0.851.14) .842Non First Nationsb 2.00 (1.293.09) .002Site of birth

Hospital 1.00 Birth center 3.58 (2.295.59) ,.001Planned home birth 4.92 (3.756.44) ,.001Othersc 2.12 (1.223.67) .008

Primary attendant at birthPhysician 1.00 Midwife 8.43 (6.4810.96) ,.001Nurse and others 4.45 (3.116.35) ,.001

DeliveryVaginal delivery, no epidural 1.00 Vaginal delivery with epidural 0.33 (0.260.41) ,.001Cesarean delivery 0.52 (0.420.64) ,.001

Infant health status at birthd

Term, no NICU admission 1.00 Term with NICU admission 0.90 (0.631.29) .559Preterm, no NICU admission 1.05 (0.671.66) .819Preterm with NICU admission 2.28 (1.583.28) ,.001

Not smoking during pregnancy 2.43 (1.803.28) ,.001

, reference group.a Adjusted for all variables in the regression model.b First Nations: the largest aboriginal group in Canada.c Others: primarily unplanned home births, also births occurring en route to hospital (eg, in vehicle).d Infant health status: preterm birth (gestational age ,37 wk); term ($37 wk); NICU admission.

TABLE 4 Proportion and Relative Risk of Being Unimmunized at 15 Months Among Those Who Received or Declined Vitamin K, 2006 to 2011

Vaccine Number (%) Unimmunized Among ThoseWho Received Vitamin K, n = 213 373

Number (%) Unimmunized Among ThoseWho Declined Vitamin K, n = 688

Relative Risk (95% CI) ofBeing Unimmunized

DTaP-IPV-Hib 11 151 (5.23) 508 (73.84) 14.13 (13.4714.82)Meningococcal 11 630 (5.45) 518 (75.29) 13.81 (13.1914.47)Pneumococcal 11 759 (5.51) 519 (75.44) 13.69 (13.0714.33)MMR 39 808 (18.66) 565 (82.12) 4.40 (4.254.56)Varicella 43 505 (20.39) 585 (85.03) 4.17 (4.044.31)All of above vaccines 10 744 (5.04) 505 (73.40) 14.58 (13.8915.30)

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Strengths of this study include the use ofa population-based design, which mini-mizes selection bias, and the linkage ofmultiple population-based registries,which enables a more complete de-scription of maternal and infant char-acteristics. The potential for bias doesexist given that data on vitamin K pro-phylaxis was not available on 19% of livebirths in our cohort. However, there is noreason to suggest that themissing statuswas dependent on vitamin K status, asmostmissingNOBformswereassociatedwith reporting from certain geographicregions. It is possible that our ndingsmay not be generalizable to regionswhere midwifery care is the standard ofcare or where vitamin K administrationpractices differ. This study showed thatparental refusal of vitamin K prophylaxisis strongly associated with subsequentnonimmunization, but does not distin-guish between parental choice and other

barriers preventing uptake of immuni-zation.

CONCLUSIONS

This study found that parents who re-fused vitamin K prophylaxis for theirnewborns are more likely to havea planned midwifery delivery at homeor in a birth center, have an epidural-free vaginal delivery, and be lesslikely to smoke during pregnancy. Theywere also more likely to not immunizetheirchild. Thisstudyprovidesobjectivecriteria for identifying parents who arelikely to refuse vitamin K for theirinfants and who are likely to have un-immunized children.

These ndings have important clinicaland public health implications. First, ithighlights the need for physicians toprovide anticipatory guidance on thebenets of vitamin K to parents who are

planning home birth or a midwife-attended delivery. Second, it points toan opportunity to engage midwives sothat education about the risks and ben-ets of vitamin K prophylaxis can beginbefore birth among a population groupthat is likely to decline prophylaxis. Third,it provides an opportunity to identifya subset of vaccine-hesitant parents whoare likely to not immunize their children,andengagethemwithtargetededucationstarting at birth instead of waiting untilthescheduled immunizationsaremissed.Targeting thispopulationearlier,andwitha provider with whom a trusted re-lationship has already been developed,may help increase coverage rates.

ACKNOWLEDGMENTSDr MacDonald acknowledges the guid-ance and support of her postdoctoralsupervisors, Dr Suzanne Tough andDr Jim Kellner.

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MODERATE IS IN THE EYE OF THE BEHOLDER: I visited friends in Boston lastweekend. The weather was perfect, so we decided to go for a bicycle ride. As wehad not previously cycled together, we spent more than a few minutes trying todecide how fast and far to ride. My two friends stated that they had been exer-cising quite a bit and that amoderate ride should be easy. After amile, however, itbecame quite clear that the three of us had very different visions of what mod-erate exercise meant.As reported in The New York Times (Well: June 11, 2014), adults are not very goodat judging the intensity of their workouts. Canadian and United States guidelinessuggest that adults complete 150 minutes of moderate or 75 minutes of vigorousaerobic exercise each week. Moderate and vigorous exercise is often dened bythe level of sustained elevation in heart rate as a percentage of maximum heartrate. Canadian researchers asked sedentary adults to review national exerciseguidelines and, after establishing that the participants understood the guidelinesand what was meant by moderate and vigorous exercise, measured their max-imum heart rate on a treadmill test. Participants were then asked to walk or jogat a pace the individual thought as moderate or vigorous and then later at theslowest pace that would be considered moderate.Unfortunately, aminority of adultsactuallymetheart rate changesconsistentwithmoderate exercise, and very few met the heart rate changes associated withvigorous exercise. More strikingly, only about one-quarter of participants ac-curately judged a pace that was at least consistent with moderate exercise. Theimplications are that many adults are overestimating the intensity of theirexercise, and that they may not be getting as much benet from exercise asexpected. Either the guidelines need to be a bit clearer or individuals, such as myfriends, need to be more honest about how much effort they have put into theirexercise routine.

Noted by WVR, MD

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DOI: 10.1542/peds.2014-1092; originally published online August 18, 2014; 2014;134;497Pediatrics

Vanita Sahni, Florence Y. Lai and Shannon E. MacDonaldNeonatal Vitamin K Refusal and Nonimmunization

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DOI: 10.1542/peds.2014-1092; originally published online August 18, 2014; 2014;134;497Pediatrics

Vanita Sahni, Florence Y. Lai and Shannon E. MacDonaldNeonatal Vitamin K Refusal and Nonimmunization

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