But a new threat looms on the horizon. A tragic condition that once killed thousands of otherwise healthy infants a year is on the rise, apparently because parents are somehow receiving misinformation about the risks and benefits of an effective preventive measure.
The condition, called hemorrhagic disease of the newborn or vitamin K deficient bleeding, can be fatal. More than a dozen sets of parents in recent years have told Mascio they don't want their newborns to receive the vitamin K injection that will prevent the condition. About one baby in 100 will develop vitamin K deficiency bleeding if they don't receive a shot, according to the American Academy of Pediatrics.
"It's not something that happens all the time, but it happens enough that we definitely want to go ahead and protect these infants as much as possible," Mascio said. "There's really no way to predict which baby will have the bleeding, but babies aren't usually born with enough vitamin K." Without it, he said, their blood "won't clot well."
Babies can begin bleeding from vitamin K deficiency at any age from birth to six months. The bleeding can be external (from the belly button or circumcision site) or internal (in the brain, intestines or other organs).
It's sometimes possible to stop the bleeding by administering vitamin K at the hospital. But in the worst cases, babies lose so much blood they need a transfusion and may suffer permanent brain damage, developmental disabilities or even death.
One in five babies who develops vitamin K deficiency bleeding will die from it, according to the Centers for Disease Control and Prevention in Atlanta.
The issue has created conflicts between parents and the medical community. Due to the increased risk that a child will hemorrhage, hospitals may not permit a baby to be circumcised if parents decline the vitamin K injection. Some pediatricians refuse to accept babies whose parents decline the shot as patients.
The problem isn't unique to military hospitals. Two years ago, Vanderbilt University's Monroe Carell Jr. Children's Hospital in Nashville, Tennessee, reported that seven babies between seven and 20 weeks old had been diagnosed with vitamin K deficiency bleeding.
Last year, the CDC reported on four newborns with vitamin K deficiency bleeding: three of the infants had bleeding in the brain and the fourth had gastrointestinal bleeding. None had received a vitamin K shot.
"Not giving vitamin K at birth is an emerging trend that can have devastating outcomes for infants and their families," said CDC Director Tom Frieden, M.D., in a statement. "Ensuring that every newborn receives a vitamin K injection at birth is critical to protect infants."
So far, none of Mascio's patients whose parents refused the injection has developed the condition, but he treated infants with it while in training. Until recently, most doctors had never seen a case of vitamin K deficiency bleeding, since shots have been given to virtually every American infant since 1961.
Mascio first saw parents decline the injections when he was posted at Fort Campbell in Kentucky in 2009, where he was previously stationed, and now at Fort Belvoir.
"It really started to become an issue. I'd never heard it before," Mascio said.
Numerous studies have confirmed the effectiveness of vitamin K shots over the past 60 years. Those opposed to the shots often ignore the vast majority of this research in favor of two reports. The first, a small study conducted two decades ago in the United Kingdom that has since been discredited, hinted at a possible link to leukemia.
In the second report released last year, doctors in Turkey said a single infant had a serious allergic reaction to a vitamin K injection. (Minor allergic reactions have also been reported in a handful of cases over the years.) Since 1 billion vitamin K shots are estimated to have been given worldwide -- 200 million in the United States alone -- the odds of an allergic reaction are far smaller than the odds that a baby will begin bleeding from vitamin K deficiency, doctors have said.
Parents give a variety of reasons for declining the shot, Mascio said.
"A lot of parents believe it's an artificial medicine that they don't want to give their child," he said. (Vitamin K is produced in a laboratory.) Some cite the outdated leukemia report, but usually change their minds after he explains that newer, larger studies show no link. Still others are concerned that receiving a shot may traumatize the infant.
"I can't force a parent to do it," Mascio said. "I try to give the parent enough information to make an informed decision."
He's been able to persuade some parents to change their minds after they learn that the best alternative to a shot is a dozen weekly visits to the doctor for oral doses of vitamin K.
Part of the reason parents aren't well-informed is that they decide against the shot long before their first meeting with a pediatrician, the doctor who is best informed of its risks and benefits. "We're trying to be a little more proactive" in sharing information with obstetricians, Mascio said.
Mascio said he works even with parents who refuse his recommendations because his chief goal is to help the child. He tries to educate parents about the problems they create for their children. Just that morning, he said, a mother declined a hepatitis B vaccine for her child, saying his immune system couldn't handle it.
"I said that's not true, but I'm not going to make the decision for you. I'll support you. Your child may have to come in more often for fevers, or get more blood tests, but we'll work with you," Mascio reported. "She said she'd talk to her husband about it."
He's hoping for the best, since she told him her husband thinks the child should be vaccinated.
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