S.B. 170 Vitamin K Amendments: transcript

Thank you Mr. Chair. Boy, you're daring to keep leaving my mic active. Thankfully I'm not mumbling over here Very much. So, Um, this bill is, uh, is a bill that came to me because of some concerns that were expressed by clinicians in the pediatric care world, but then personally as myself as a care provider, uh, when I had a specific case, uh, this came to me and, and without hopefully going fully down the weeds, and I did apologies for my academic self that printed out all of the graphics and the pictures of what a cerebral hemorrhage looks like and the things are in the pieces that I gave you. Um, I wanted to explain a little bit of what this bill is about, and it is about the administration of vitamin K in the form of an injection in newborns. And it's something that over the last number of years, I would say decade or so, um, we have seen a change in the amount of people who are wanting to refuse of vitamin K injection. And I understand there's, there's pieces out in our society that have made people skeptical of medicine and of pharmaceuticals and of all sorts of things, right? We've gone through a lot in the last 5, 6, 7 years that have given people pause. But this one in particular is really concerning to me because if you don't have a vitamin K injection at birth or shortly within the birth window, what can happen is that you can actually hemorrhage, which means that your body's ability to clot is not established well enough. And without that vitamin K, especially if you're a vitamin K deficient individual, baby tiny, you are at risk of hemorrhage, which means bleeding. That can be bleeding into your brain, that can be bleeding into your gut, into, you know, your stomach, your GI tract. Um, there was one child I heard about that had unfortunate bleeding into a testicle and lost that testicle. And so I wanted to find a way that wasn't overly heavy handed, but that really tried to get us as a state and as providers and as hospital systems to introduce some safeguards, some education, and also a process by which we could honor parents who truly had made the decision that they did not want to go this way. And so we looked at different states. Um, Florida only allows a religious exemption out of getting it. Another state, um, mandates A-D-C-F-S referral for anyone who refuses to get it. I, I didn't wanna go those ways that didn't feel right to me and that didn't feel like it honored, um, that spirit that I truly do respect in the physician patient relationship. And that is that we ensu good intent and we want to help people take the best care that they can and that they're comfortable with at their children. So this bill essentially, um, has a requirement that a healthcare provider or, uh, or, uh, midwife people in the more direct spaces administer vitamin K within 24 hours to an infant. But if parents don't want to, there is an opt out process and they can sign that they don't want that after they've been given some education. So they're sure they understand what their opting out of, and that's not at all meant to be punitive. That comes basically from an experience I had, um, from a, a little baby who had a bleed into their head and the dad who wailed and cried and could not get past the fact that he didn't know what he had refused for his infant. And that really stuck with me that we are all allowed to make decisions, but we want decisions to be informed as we move forward. Um, I did get you all some handouts as well. You can see one of the graphics, I sorry, the numbers are so tiny members in the audience, but, but essentially between 2018 and 2025, our refusal rates of vitamin K in our newborn spaces have gone from about 1% to 6% the numbers of increased bleeds or of intracranial or other bleeds that we've seen. I had never seen a bleed in my 25 plus year career until this last year, and I've seen three of them. So, um, it, this bill, like I said, is my desire to help educate and help people know and be informed by sources with information that is actually informed and not perhaps just rumor mills or social media or some of those spaces. Uh, I do know there are some folks to speak to this well. So I'll, um, move forward with letting them join the conversation. Okay. Thank you. Thank you.

Exactly. Okay.

Thank you, Mr. Chair. Well, it's, is it on? Yeah, it's on, right? It is on, yes. Thank You Mr. Chairman, members of the committee. I'm Dr. Jennifer Brenton. I'm a pediatrician in complex care. I take care of the most fragile kids in the, in the state who have technology dependent. So we help them get their wheelchairs, they're feeding tubes, their ventilators, and often many, the kids I have don't have a way to prevent their illnesses. That's why I speak in favor of SB one 70. It gives families a way to help prevent some important things that that can happen to kids. We know that at birth all babies are deficient in vitamin K. There's not a good way to moms to take extra to supplement babies. It just doesn't seem to cross that placenta well enough to get there. So vitamin K shots are one of the best ways to do that. We've been doing it since 1961, so we've got generations of good safety data on that as well. Um, if newborns don't get the shot, they're 81 times more likely to develop serious bleeding, which can be without warning. So suddenly into the gut, suddenly into the brain, as Dr. Plum was mentioning there. And unfortunately, that stroke can cause permanent damage. One in five kids can even die from that bleeding. And this bleeding risk lasts the first six months or so of life until kids are getting enough exposure to other sources of vitamin K in their environment. Because we want families to truly have the freedom to choose the medical care they feel is best for their children. I really support this bill in that it requires providers to make sure they're truly giving families the access they need to information to make an informed decision. These decisions can help keep our children healthier in Utah. And for that I support SB one 70 and urge you to support it as well. Thank you.

Thank you. Hello. Thank you for letting us speak. Thank you Senator Plumb for bringing this to everyone's attention. Um, and I agree with you that this is currently a, a huge problem for us. I'm not gonna repeat the data. I'm sorry. My name is Dr. Chris Campbell. I'm a pediatrician, um, here in Salt Lake. I also represent the Utah A A p, um, uh, speaking in favor of this. So I think in addition to all of the really important medical information that Dr. Brenton shared with us, I think one thing that we need to recognize is that we are in an era where we really need to be encouraging our medical providers to speak clearly and with good data to the folks that they're serving, right? We used to take for granted that people believed we were doing the best thing for them. There's a lot of competition. Now, it's a good thing to force us to explain why someone should consider getting a vitamin K injection. Oral vitamin K. Many of you may have heard of is something that you can take, it's a second line treatment for people who opt out of vitamin K. You have to give it every single day for 90 days, and it doesn't work as well. And it works more slowly. And in the meantime, the kids that Dr, that Senator Plumb sees in her er and that I get called about in my hospital, um, are having lifelong, uh, uh, life-threatening complications from this. But, so I think that this bill makes, it puts the onus on the provider to really explain why this is good. This is not a vaccine, this is something different. And it really is lifesaving. One of the anecdotal bits of information that we've heard around the community is that our physicians who work in labor and delivery units are being told by parents, we don't want a vitamin K shot. And when they're told appropriately, I'm sorry, we cannot circumcise your child, your son, because that's a sixfold risk of, of severe bleeding complications with circumcision if we don't give vitamin K. So we refuse to do that. They change their minds. And you know what that means? That means that they're making the decision without data. Force us to give them the data as to why they should do this and make them make the same decision for their sons and daughters based on that decision, not just when we suddenly start talking about circumcision. Thank you very much for considering this. I think it's really important. Have a good day.

Hi. Marian Martindale, CEO of Utah Academy Family Physicians. I won't, um, repeat all of the medical reasons why, uh, people should take have, uh, their infant given vitamin K. Um, I do wanna point out one thing. Um, uh, Dr. Campbell mentioned this just slightly, but it's not a vaccine. And I think too often it gets looped into some of the concerns with vaccine. It's a nutrient, it's a vitamin that they do not produce at birth. They do not get a sufficient amount through breast milk. They don't have the butt, the, the gut biomes to, to create it from any of the things that they're given. So it is critical for this, but to the point of this bill, information is power. This just gives the parent the information needed to make an informed decision and make the right decision for them and their child. So I urge your support. Thank you.

Thank you. I'm, I'm reading the language. I'm a bit concerned. It, it's not about, you know, the, the merits and the wisdom of, of doing this shot, but I think we have to adjust the language in this bill in line 28. Uh, the healthcare provider is, is required to issue the shot. And then in line 32, a parent may decline if the healthcare provider or unlicensed midwife provides a full and clear explanation of, so we have that you ha you shall provide the shot, but there's no, you shall provide the information. I think there's a, a challenge in meeting the intent of, as I understand, of what you're Trying to do with the, with the wording.

Yes. This should you, you should have the healthcare provider shall, uh, do what is in line 34 and 35 and then off and, and express that the parent can sign a form if they desire to get, uh, it's, it's a little bit, we're not, I hear what you're saying, what we're saying we're the, we're you shall provide the shot, but there's no shall provide the information about the shot.

And I to the witness's point, I think that's, that's what we need to do in the language. It's not meeting the intent of what you are saying. Would You?

I would, uh, would Your recommendation be?

I I think it's such a clear and and appropriate change that I would absolutely commit to working with the drafter to make sure it's there on the floor. If that's comfortable for folks, if that's not as comfortable and you'd like me to circle it, I could even ask 'em to work on it now while we're in committee and see if we get there.

Commitment from this senator that by the time we hit it on the floor, we move, you know, debate on second and on third. It's ready to prime for prime time.

No, I waive. Thank you for that, that smart input.

All right. Um, thank you all again. As we get near to the end for having me here. Um, this bill is one that I, I am really interested in the conversations as much as I am, uh, in the policy on it because I think that, um, there have been some trends that we've noticed in, in pediatric medicine in particular and in neonatal and newborn medicine that kind of give pause and have made me wonder a bit about what could we do better to help families in this, both exciting, exhausting, and wonderful, but sometimes terrifying time to have optimal information to make the choices that they see best for their families. And this bill deals with the administration of vitamin K. Um, vitamin K is administered to newborns and has been for years, if not decades, um, to kick off what we call the clotting cascade. So your body needs vitamin K to kind of start clotting, which means stop bleeding. If you make little clots, you stop the bleeding. And if you think about even the most, um, easy birth, it's a traumatic experience. It's a babe squeezing through a canal, and there's trauma that happens and there's squishing that happens, and there's what would cause a bruise typically. Um, but if you don't stop bleeding, it's becomes more of what we call a hemorrhage, which is a larger collection of blood and can be dangerous for an infant. So since the start of giving babies vitamin K and it is administered in a, in an injection, the oral form of vitamin K doesn't work the same way. Unfortunately, it isn't present in breast milk. Um, we have really limited the number of what we would call vitamin K deficiency related hemorrhages or bleeds. And over the last, you can see one of the graphics that was passed out to you that has kind of the colored graphics bars on it. You can see there's been an increase in the refusals of vitamin K injections. That top one is, uh, just from Intermountain Health on their, well, baby nurseries, so not their neonatal, um, ICUs, but their well baby nurseries. And you can see since 2018, apologies that you have to have even more than readers to get those numbers is from 2018 to 2025. The blue bar graph is a refusal of a medication called erythromycin, and that's something that's put in the eyes. And the gray medication, or the gray bars are a refusal of vitamin K, and that's from about 1% of birth to about 6% of births. We are still working, um, on watching the increases in numbers of hemorrhages, which that's the second picture below that. Sometimes when you look first at these scans, they look a little like if you're me, at least they look a little like Halloween pumpkins that have been, uh, carved out. But what they actually are is they're images of brains and where the white, bright white is, that's actually bleeding. So these are just an example of a baby with it that's had an intracranial hemorrhage. Um, and as we are seeing less vitamin K administration after birth, we are seeing increased hemorrhages. I had never seen, um, uh, one of these hemorrhages in my 25 plus years until the last year where I was either involved in or adjacent to the care on two infants of these. Also another infant that lost a testicle because of a bleed into a testicle that the bleeding wasn't controlled. So this got me thinking, how can I help us as a commu, as communities, how can I help us as medical providers? How can I help us as parents be more thoughtful and worked through incarnations of this bill? Talked to different, um, of our LRGC folks and different policy folks around the nation and, and different colleagues and found some states absolutely require vitamin K admission. I think it's Illinois, it turns into A-D-C-F-S, uh, referral if vitamin K is not administered. That seems a little heavy handed if you ask me. Um, Florida does require, um, uh, vitamin K administration with an opt-out policy. So I, I was trying to devise something that I thought would be more, um, palatable for Utah, but would still potentially advance where we are. So, started in one place, had an amendment or a sub adopted in the Senate. So that right now where this bill exists is that it would, um, basically help us set up a kind of a statewide standard that we expect, um, a healthcare provider or licensed direct entry midwife to, uh, provide the education around vitamin K. Now, some folks looked at that and went, hang on a minute, that's a lot of weight, potentially on one person. Well, if you look at code, and I can forward you all this 12 line description of what healthcare provider is in our code, a healthcare provider includes any person, partnership, association, corporation or other facility or institution who causes, uh, to be rendered or who renders healthcare or professional services, such as, so this doesn't have to just be a doc. This doesn't have to just be a provider. It can be a hospital, a healthcare facility, a physician, a physician assistant, a registered nurse. So you get where I'm going with this. There is a very exhaustive list. So saying healthcare provider does not mean any one individual. It means us as a system for each individual system to work out what's best for them. And I, I didn't, knowing this time and knowing specific kind of concerns from people, I wanted it to be clear that there was an opt-out process that this isn't a heavy handed, I want you to do this or else, or there's a judgment. I wanted it to be clear that if this is something you don't want, there's a an established opt-out process that is in the policy. So, um, that's essentially the bill. I have all sorts of information I could teach you and go full medical school on you on, um, clotting, cascades, et cetera, but I think no one is likely interested in that. So I'll spare us all. Um, I do know that there are, um, multiple folks that have joined us as well. So I would certainly love to have them share their information, and I'm open to questions from you all as well.

Thank you, Madam Chair. Um, thank you, Senator Plumb. I I really appreciate what you do for children, and I appreciate the intent of the, the bill. I do have some concerns. Sure. Um, one of them is the education on vaccines is typically one-sided. It tells you maybe a few minor things, but I've read enough package inserts to know that there are a lot more things that we need to be concerned about than we're told about on the VIS. And so I have the same concerns about this there on, on most of the vitamin K that I've seen. There is a black box warning, which indicates that there is extreme risk because you don't have a black box warning, warning with DTA or MMR, or I can't remember all the ones that don't. And I think we have a pharmacist who can speak to some of that better too. But yeah, keep going. Sorry. Okay. So I would be concerned that when you're educating parents that they are getting the entire package insert and the entire education and not just the pretty little VIS that we usually see at vaccine visits. Um, I'm also concerned that I feel like this could maybe be an education thing instead of a mandate, which basically it is a mandate because you're saying if you don't opt out, then you do get the vaccine, right?

No, No, No. It, it, when it started, initially the bill was for administration and then with more conversations with folks, so it was administration and then also a clear opt-out process. And then with more conversations with people didn't have the right temperature check for, for decent chunks of the, of the state. So, so it is just an education requirement. And I considered pulling out the optout part, but people told me that having an optout, there felt actually, um, like it wasn't an attempt to force something that it was clear that this would just be established, that there wouldn't have to be a fight for an optout, that it would just be established. I can absolutely pull that opt out out. The bill is just for education.

Okay. So just so I understand, we're not talking about opting out of the vaccine, we're talking about opting out of the education.

No, opting Well, that's a good point. The way I had it written was opting out of the vaccine, I suppose opting out of education there. It could be an opt out of an education piece if that's, I hadn't even thought of that possibility, but that's, that is a

Possibility. Okay. Then not recording whether they opted in or out to the vaccine is that

It's not, it's also not a vaccine. It's

Vitamin K, but it's not just vitamin K. It is Though either. It is, there's more stuff in it than vitamin

K. There's no aluminum in it, there's no preservatives.

But I'm not saying there's aluminum. I'm saying it's not just vitamin K.

Okay. But it's not a vaccine. It's ly Not a vaccine.

Okay. And then a another concern is just having parents sign a form that says that they acknowledged the risks. Years ago we had the, um, administrative rules committee advise h uh, well, I can't remember if it was DHHS or HHS then it was before that got changed, um, that they were not to put in the paperwork that the parents were assuming any kind of risk or, or saying that the, the parents were implying, I guess, that the parents were causing a problem by not getting the vaccines. This was for vaccines in general. So it used to be that the parents had to sign something that said, I am aware of the risks involved and I, and that I'm endangering my child. Basically, they had to sign that I've never seen that was removed. And I feel like this is kind of leaning back towards that. If you have them sign something that says, I'm aware of the risks and I'm opting out. Interesting. I, I Know. So those are just some of my concerns. And then I'm also a little concerned about the unlicensed midwife part, but, um, that's basically it.

Well, I thank You. Okay. If, if I could respond a little, I think that something I didn't include was one of the stories from a father of the, one of the babies that I did take care of. And he was beside himself and so upset that he didn't understand that a bleed into the brain, which is irreversible, that's not a treatable thing. Hopefully with time, that plasticity of, of babies' brains, they, they do amazing things. But he was so sad and he was, he, he had such grief over the fact that in the chaos of that birth time, he didn't understand fully was at least what he was passing on to me. And so I think I do understand some of the what ifs and the, um, I don't know if, I can't think of a better word than almost some of the like pseudo conspiratorial kind of notions around it. But the hardest part for me is that when you work in a space where you treat preventable illnesses or injuries and, and you see, well, what could have, for me, an educated parent choice is the, is the ideal, right? Like parent choice and an educated parent choice is parent choice with a gold star on it. So I think that I, I guess I forget that I, I I am prone to assume good intent, perhaps more than I should, but you know, from my colleagues, that's where I am coming from, is this place of trying to give information so that families can truly make the best decision for them.

Thank you, Madam Chair. Um, I'm gonna go down a different line of questioning, if that's all right. Um, I guess my, my question on this is the inclusion of the unlicensed direct entry portion. So they're unlicensed, which means we don't have a set state standard for what those education requirements are. And so providing someone where we don't know their background, requiring them to explain a health product and, um, a health procedure and to clearly articulate, I guess, what risks and benefits are. I, I don't know if that's the right person to do that, if that makes sense. Like, have you thought through that?

Yeah, and I, and I did kind of, there's some gymnastics around it, right? Because there are people that everybody chooses to have delivery of their infant in their, in their particular way. Some folks that's a home birth, some folks that's a hospital birth, some folks that's a tub in the living room. And there's all sorts of versions of what that looks like. And so I wanted to be, um, mindful of the fact that not all deliveries and healthcare happening within a hospital, that I also wanted the folks that choose a, like a midwife path and perhaps outside of a hospital setting, would also have that opportunity to have that informed, uh, educated parent choice piece. Um, I did get some contact back from some of the midwife folks who suggested some language changes related to what they can and can't do within the scope of their practice because, for example, they, they aren't administers of medications. They aren't in the same line. Um, but yeah, I mean, that is an interesting thought. I just didn't want to cut out a whole chunk of our population who that's the way that they choose to, to bring their babies into the world. So,

Yeah. And, and that makes sense. I guess just my concern with that is we already don't have a standard for even what they know. And so then to go through and require them to provide a full and clear explanation for the reason of the administration and the risks of possible adverse health outcomes, I guess I Juab I don't know how we measure that and how we track that. Yeah. Um, you know, if it were just a, hey, hand out this form with some information on it, that would be a little bit different than requiring someone who doesn't necessarily have any formal medical training to, to go through and, and educate. I guess that that would be where, where my questions on this come From, where your pause would be.

And, and I hear that. I think too, perhaps part of the, again, me and my assuming good intent and collaborations and, and bridge buildings, I know DHHS now has a all sorts of, uh, there's some folks here that might be able to speak to it, but have all sorts of informational pamphlets that they do produce that can be set in the spaces. Um, which I, I know then probably also, um, to represent Shire's concern. Well, what is in those, what's, you know, who's putting, who's deciding that sort of a thing in there. Um, and this is one of the challenges about healthcare, I think in all times, but particularly in this time, is how do you facilitate people knowing what you hope is enough to know and the right things to know? And then granting them the autonomy while still also hopefully guiding them into spaces that's the best wellness for them. Our little infants that have almost nothing, I feel like need a little extra. Um, and maybe, maybe, I don't know, maybe there is a, a piece of, uh, the collaborations that I would hope from Intermountain Healthcare in the University of Utah and with, from within our DHHS spaces where there would be resources available to some of our midwife types, et cetera.

Yeah. And I, I guess I would just, my pause is just you've got someone with an, I mean, a license is one thing, right? There's an enforcement mechanism, there's a guaranteed level of training or education, apprenticeship, whatever. Yeah. You wanna call that. But when we're specifically targeting unlicensed, I mean, maybe, maybe the neighbor next door ended up helping you deliver your baby 'cause you weren't gonna get to the hospital. And so under this, would that person then be required to educate you on the pros and cons of vitamin K? And, and so I guess that's, that's where my hesitation comes in. Sure. It's not, it's not what you're trying to do necessarily. I just, on that particular piece, I don't know how we do that.

Sure. No, that's, that's actually fair.

Thank you, representative gracious. Um, I'll just, I have a couple of questions Sure. And maybe a comment on that. I think that's, you bring up an interesting point about direct entry rifs in general as well. So that's also maybe something that needs to be looked at. Um, I just had a quick question. We, I quickly called my floor. I used to work on a floor and administer these shots all the time. Yeah. And it's been like five or six years. So I called one of my nurses and I said, tell me the protocol for this again. And she basically described exactly what you have in here. And I said, oh, well, we have a bill today that's saying this thing. And she says, well, we do that because it's our, it's state code. And I was like, oh, it's actually not state code. So it's interesting that they're actually already doing this in the hospitals, at least anyway, at least in my hospital. Um, they're giving that education. I know that babies, if they're gonna have a circumcision, they cannot have a circumcision unless they have the vitamin K. So that usually will change someone's mind if they're wanting to have their baby have that because of the bleeding risk. So just some interesting thoughts there. Um, I, my question is, you said that there's still some research being done on is the level of hemorrhage rising? Mm-hmm. Do you have any idea of if it is with all of the people who are declining now? So the, the graphic, the preliminary and completely unofficial ish graphic that I had gotten from, uh, one of the folks who works in pediatrics within the Intermountain system was, it looked like, uh, and these are small, right? These are not something that happens a hundred times, uh, you know, a month or, or a year or any even. Um, but that there had been, you know, maybe one a year then to zero to zero. And it does seem to have then risen from three to five to so on scale, um, you know, up to five times, 500% more of them. But that's all very preliminary and almost essentially anecdotal because we're going on ICD codes and, and on in what individuals have seen as opposed to a deep dive. Um, and I have another question is, has there been any thought to looking to, uh, maybe only doing it if there is, you know, something that is like they've had a lot of trauma with the birth, which most have, you know, we, we know that through the birth canal, if they go C-section, maybe there's not as much bleeding. Is there any thought too, instead of just giving it to everyone to try to catch everything, like, has, has that ever been a part of the conversation? I think that's kind of what some of the questions from people who are like, why are we giving this to everyone? Yeah,

That's a great question that I would probably defer a little more to the, or like neonatology types who we may have with us here, since that's their sole world, is around the brand new arrivals of folks. I think that when something is easily preventable and also happens infrequently enough that it's a larger scale, um, I, I would think it'd be pretty hard to predict this person has a five x risk, this person has a two x risk, I would think. But, but it is an interesting question to look into is especially if there is, you know, continued adversity to this, um, and folks having discomfort with it, um, especially if then to try to set off some sort of a hierarchy of risk. I do know, you know, in speaking with pharmacists at Primary Children's that all of the preservative has been, they're only administered preservative free vitamin KI mean, people are listening to the concerns that folks have. And I, as we go along, there likely will be some evolution in that too.

Uh, thank you. I just wanted to address the concern was, was brought by representative gracious regarding unlicensed midwives. Mm-hmm. Um, a lot of times as I look at legislation, I think if there's not an enforcement mechanism, we don't have a policy unlicensed midwives, I have no idea how we would enforce that. And like if we found out they were doing not following this, like, what are we gonna do to take their license away? No, they don't have a license. Strong conversation. YY yeah. So my question is, is if this bill moves outta committee, would you be willing to entertain a floor amendment that would just strike out the midwife section, since it's brilliant unenforceable anyway? Yeah,

I, I think that that's, you know, I hadn't thought in depth about that, and I think that's absolutely reasonable. Okay. Thank you. Reasonable.

Good afternoon, Madam Chair and the representatives of the committee. My name is Hannah Finky. I am a triple board resident. Um, that means I practice pediatrics, adult psychiatry, and child and adolescent psychiatry with an interest in going into the NICU of all things after this. And I'm speaking as representative of the Utah a a p in support of SB one 70. And so Senator Plumb already talked about a lot of the benefits of vitamin K. It is a fat soluble vitamin needed to prevent bleeding. Uh, babies don't have adequate levels of vitamin K in their systems. It's not transferred well from the placenta to the baby. Um, you need a mature intestine to absorb vitamin K, so that prevents babies from absorbing it. And then very low levels of vitamin K are transferred through breast milk. And so, like Senator Plumb mentioned, we have been administering vitamin K since the 1960s to prevent vitamin K bleeding. And so it's very important that babies get this, uh, vitamin for several reasons. Uh, one question that you had asked Madam Chair is, well, is there a way to stratify which babies need vitamin K? And really the answer is no, because there are various stages of vitamin K deficiency bleeding, and so there's the early vitamin K bleeding, which vitamin K can't really, um, prevent. But there are two other types, classical bleeding, which happens in the first week of life for babies, and then the late onset bleeding, which can happen all the way through six months of life. And so, if you can imagine six months in a baby's life is a really long period of time, and you cannot predict, you know, if a baby's gonna take a tumble, if, um, they are gonna experience any other medical concerns. And so for those reasons, I think vitamin K is crucial for all babies to have administered at birth. And so for the babies that do not get vitamin K, they're 80 times more likely to experience these bleedings. And of those who experience those bleedings, one out of five will die. And up to 50% of those, um, will have lifelong disabilities if they do survive. And so that is a really important thing to consider. Um, like Dr. Plum, uh, mentioned, the refusal rates have been increasing over the years. And so, um, the a a P mentions data around one to 3% of a national refusal rate. And then recent studies have shown about 5% refusal rate. But we know that that, uh, that numbers likely under representing the total population because likes under Plum had mentioned some families prefer to do home births or to birth at a birthing center, and we don't always have that data to represent how many babies are not receiving vitamin K. And so from my own experience working in the well baby nursery and in the nicu, I, I believe that every family deserves the right to receive education about vitamin K. I truly believe that every family wants what's best for their baby. And I think having all of that education really equips them to be able to make a decision that's right for their baby. And oftentimes we're having these decisions, or we're having these conversations with families right before baby is coming. And that's often a very stressful period of time. Um, this bill doesn't really speak to when is the best time to have these conversations or how to have those conversations. Um, but as an aside, one of my research projects, if I get a grant, would look at partnering with community partners, midwives, things like that, to talk with families to figure out, Hey, when would you like these conversations to happen? And how would you like these conversations to happen? And so just know that evolving projects are going on about that.

Thank you, Madam Chair. And I'm not sure the nature of your practice right now. Do you work right now in the nursery? No, I'm a resident, so I do rotations in Do you rotate through there still? Sometimes, yes. Yes, I do. Just on your rotations? Yeah. Well, just on a personal basis, what's been your experience? Do you feel like you have noticed more people who have refused to have the shot? And when you have had the conversations mm-hmm. With them, have you found that they were open to your explanation? Or have you found that most of them came in with a preset decision, that they're pretty firm and, and no longer were interested in your input? What's been your experience? Yeah,

Every family is different, I would say, um, similar to Sun Plums data at Intermountain, we have seen similar data at the U as well. Um, there's ongoing research on those numbers, um, in particular. And then anecdotally, usually families will, um, if they are resistant or hesitant, it's about all three of the new more interventions, vitamin K, erythromycin, and Hepatitis B. Most families are willing to at least, uh, listen to vitamin K. And if they are to agree on one, it's usually vitamin K, usually for concerns about circumcision and the risk for bleeding if they do choose to circumcise their baby. And so, um, I would say that most families do have some reservations going into the conversation, but most are willing to at least hear the conversation with some families ultimately deciding not to do that. Yeah. Thanks. Yeah. Thank you. Yeah, thank you. Those are all of my comments. Thank you for

Good afternoon, chair and members of the committee. My name is Melissa Anderson and I'm with, uh, healthy Roots Foundation. Uh, Utah has a strong tradition of respecting parental rights and preserving family authority in medical decision making. This bill requires parents to be informed of the risks of declining the vitamin K injection, and to sign documentation, acknowledging those risks. However, it does not require equal disclosure of the potential risks associated with the injection itself, including documented adverse reactions and the FDA box warning. Nor does it require informing parents of available alternatives such as multi-dose oral vitamin K protocols, that lack of symmetry matters. True informed consent includes the risks and benefits of accepting and declining an intervention, as well as reasonable alternatives. When disclosure emphasizes only one outcome, it shifts from informed consent towards directed consent. If the legislature formalizes this process in statute, it should reflect Utah's commitment to parental authority, transparency, and limited government intrusion into routine medical decisions. At a minimum, any mandated disclosure should include balanced risk information and acknowledgement of alternatives. So I respectfully urge the committee to vote no today on this bill as it is written. Thank you.

Thank you for your comments. I have a quick question for you actually. Thank you. Um, you said, um, the risks associated with vitamin K. What, what are the risks that are associated with it?

So, as representative Valier had mentioned earlier, there is a black box warning on, uh, vitamin K. Um, and there are, if you go onto, I believe it's vaers, they have, um, some, uh, adverse reactions. I don't know all of them, um, but there are, uh, documented adverse reactions. Okay.

Thank you. Thank you, Madam Chair. So I've just done a quick, um, quick search on the, um, literature on the risk of vitamin K injections. Um, most common risks are pain, bruising, and swelling at the injection site, extremely rare, estimated at one per million, um, estimate a serious allergic response compared to the relative risk of seven up to 7.2 hemorrhages per 100,000 versus so much smaller, um, denominator seven 100,000 versus 1000007.2 versus one. So the relative risk there is about 70 times just for to answer that question.

Uh, my name's Dr. Stacy Bank. I'm the Executive Medical Director for the Department of Health and Human Services. Excuse. Um, I I wanted to just speak a little from a public health, uh, perspective. So, vitamin K deficiency is a baseline biological deficiency that is present in every newborn, regardless of background or prenatal health. So vitamin K doesn't cross the placental barrier effectively and is found in very low concentrations in breast milk. So all infants are born with a physiologic vulnerability to the vitamin K bleeding, which is silent and, and manifests as sudden life-threatening intracranial hemorrhage could without prior warning. So from a public health perspective, providing a one-time $5 intramuscular dose, we effectively bridge this 180 day nutritional gap, which can prevent a catastrophic neurologic trauma that carries, as we've discussed, a 20% mortality rate and a 50% chance of permanent disability for survivors. So also, from a fiscal perspective, looking at proactive intervention is a matter of responsible stewardship. Negligible cost of a single shot stands in stark contrast to a potential multimillion dollar lifetime cost for a single preventable brain bleed. So DHHS does maintain that this prophylaxis is a foundational public health measure essential to ensuring the safety and long-term developmental potential of the children in our state. And I also just wanted to bring the conversation back around. Um, I know Representative Shelley had a question about some of the, uh, educational materials. So we have newsletters, we have, uh, digital newsletters or one pagers that we can provide for providers, mid-levels, um, or excuse me, midwives. And, um, we can also create any other educational materials that would be requested or, or mandated, uh, with this bill.

So much. Uh, I appreciate everybody letting me be here. I'm gonna be very brief, but wanted to have two perspectives. One is I'm a dad. I have two kids. If,

Oh, sure. Who you represent first and then, sorry. Sorry about that. My name's Dr. Jeff Robinson. Um, and I'm just representing myself. Uh, I think from two perspectives. Um, one is I'm a dad. I have two kids. Um, and I remember the day that they were born and it was harrowing and it was, um, exhausting and is, it was exciting, and I didn't even do any of the work, right? Um, and so, uh, I think that in those, in those days, as a parent, you're really trying to get the best information. 'cause one of the things that anybody who's had kids understands that immediately you're just overwhelmed with this feeling of, I, I, I will do anything to protect this baby. And so the ability to have good education and good information, you're just desperate for it in that moment. And you remain so, uh, even when your kids become teenagers. Um, the second is I'm a pediatrician as well. Um, and I think one of the secrets of being a pediatrician, that is one of the best parts of the job. I think everybody can maybe understand how it's really great to work with kids, but actually one of the things I love most about my job is working with their parents. 'cause parents, I think one of the things universally, I mean, I've worked with parents in Utah across the globe, um, in many different settings, is all parents love their kids. Um, and, um, and so I just really love working with parents. And I, we try our best to provide them with good information and good education. Every child goes through childbirth and all of us die. Those are two universal things. I think that that's why this bill, I think is makes a lot of sense. It standardizes some good education. I agree that there should be both sides, but it needs to be evidence based. It's not enough just to say like, well, you need to have like both sides. You need to have, it needs to be based on evidence. And so I think appreciate, uh, representative Daley provoke bringing out some of that evidence because you really want, you really want parents to have good education because ultimately, as as pediatricians, we support parents making the decision for their kids. They love their kids more than we do, even if we think we love their kids, the parents wanna do the right thing for their kids. This bill, I think, helps us take a step towards standardizing a very low risk, but highly effective intervention that can prevent lifetime and long-term consequences that all of us have seen. And so that's why I support this. Thank you. Thanks,

Um, thank you Madam Chair and members of, of this committee for serving on this committee that seeks to, um, improve the health of all Utahans. My name is Taylor Boyd, and I'm a third year medical student at, um, planning to pursue a career in pediatrics. I'm here speaking for myself only. Um, I wanna support the SP one 70 because without vitamin K, roughly one in a hundred newborns can develop a severe bleed into their brain. This number one in a hundred may seem very small, but like I'm sure many people in this room do, I have a very large family, and it's roughly the total number of my cousins and their kids on one side of the family. There were about a hundred students in each grade in my elementary school as well. Each case of this disease, hemorrhagic disease of the newborn, has about a 20% chance of death and a 50% chance of permanent irreversible disability in my elementary school. That would mean that one child that would've attended school and believed in the tooth fairy and memorized the vision facts and played endless games of tag would instead die in infancy among the survivors. There would be children in three grades with profound disability disabilities. That because of the challenges of prognosticating a baby's brain to adulthood can often be hard to determine early on leaving loving parents anxious about what milestone and child will miss next. One of the most difficult things that I've seen in medical school thus far was a baby that literally had a hole in his brain from a different, a different condition, but who was still acting completely normal. Because as a doctor said, you don't need much brain to be a baby, but you do need, do, need one to grow up. Um, and that number multiplied by the 587 elementary schools in the state of Utah grows to an immense number of children that would be suffering unnecessarily. In my experiences in medicine, some of the most painful tragedies are, are those that are completely preventable. Everyone is here today is present because they want Utah's children to have the best chance at a happy, healthy life. Passing this bill will help inform parents about how to keep children safe and help increase those chances. Thank you.

Thank you, Madam Chair. Um, my name is Charu. I am a pediatric resident, um, and I care for pediatric patients, um, in the Utah Valley. And I'm here to speak in favor of SB one 70. Um, I just wanted to share a little experience that I've had taking care of a, uh, baby in the pediatric ICU who had a brain bleed after, um, a vitamin K due to a vitamin K deficiency because, um, she hadn't gotten the, the vitamin K shot. And, um, there were no other, um, trauma or, uh, conditions or risk factors that could have resulted in this bleed, um, for this baby. And all the brain imaging that we had gotten as part of her care showed us that this was most likely the cause for this bleed. And this baby, um, was born normally, um, there, vaginal delivery. There were no, um, big complications during birth. There were no complications during pregnancy, so this should have been a normal healthy baby that was able to go home on day two of life with mom and, um, um, and be healthy. Um, but unfortunately she ended up in the ICU and, um, now has, um, a lot of neurological devastations, um, that she will have to live with, um, um, on a day-to-day basis, um, as she's, as she's growing up. And, um, this case was really, um, uh, it really impacted me because it could have been prevented. And, um, there, I think a lot of people have talked about, um, the different phases of vitamin C, bleeding, why we need to get the shot and what helps. Um, but I think, um, there was a great point that was brought up that parents should have, um, information and education on the negative side effects as well. And we've heard a lot about this black box warning, um, that is on the vitamin K shot. And, um, to clarify that black box warning is that there can be an anaphylactic or an allergic reaction that can be severe and life-threatening. Um, however, from the research that we have done in looking at the literature, um, there has been, um, we believe, uh, a single case report that has described, um, what's believed to be a case of neonatal or, um, anaphylactic shock for in babies, um, following, um, vitamin K administration. And a lot of this black box warning, um, uh, I believe was more relevant with the older IV formulations. Um, currently the vitamin K that we administer in the hospital is an intramuscular shot, so it's not given through the iv, it's, um, uh, an injection, um, on their thigh or, um, intramuscularly. Um, and so that, um, administration, um, of the vitamin K shot does have a much lower risk of, um, anaphylaxis. And there are, um, there the prevalence is three in 10,000 cases. And so, um, like, uh, someone else had mentioned previously, I think the benefit of giving the shot is much higher than the risks, um, and this black box warning of anaphylaxis. But I do agree that parents should receive education about both the pros and the cons of, um, the medication and have the ability to make a well-informed decision. And, um, currently in the hospital as residents, we are, um, more than happy to go and talk with parents and families, um, and answer their specific questions on the risks of, um, getting this shot. And I think standardizing this process we'll make sure that every child, um, gets the best chance, um, that they deserve. Thank you.

Go ahead. Thank you Mr. Chair, members of this committee, Michelle McCumber with the Utah Medical Association, we would also urge you to support this bill. Um, we do think giving, um, parents information on both risks and benefits of what happens in healthcare is the best that we can do and help them make good decisions by having this information, um, that they have available. We do think, um, and we have seen from the different testimonies and from information presented by, uh, representative Provo daily, Provo, that the, uh, benefits outweigh the risks. And we do think that, um, parents having this information will help them make the right decision so that hopefully their child doesn't, uh, have uncontrolled bleeding just because they decided not to take the vitamin K, we would urge you to pass this bill forward. Thank you.

Sorry, I had to be joined. Um, my name is Carly Hay and I'm am a residency trained and board certified pediatric pharmacist. I've been practicing for over 10 years, so, um, mostly here to speak to a couple things related to vitamin K, its ingredients and the black box warning, and then also a little bit about the education that's provided on a public facing level. But I think, uh, Shari talked nicely about the black box warning for anaphylaxis, and she is correct. Um, it mostly comes from the IV version, which is still a risk when given iv and it's related to rapid administration of the medication. Of course, intramuscular administration of the medication is a slow process where it's then absorbed into the body. So that's the first piece. Um, the second piece is around the ingredients. So actually, um, in what is, uh, essentially the, the large health system in Utah, we have public facing education materials and, um, materials that we provide to infants, uh, and families at birth that, uh, do include things like all of the ingredients inside of the vitamin K injection. So those are polysorbate 80 poly, uh, uh, propylene glycol acetate, glacial acetic acid. And those are just four things that essentially one, lower the P or, uh, increase the pH of the medication to prevent, uh, pain and also stabilize the medication and ensure nothing separates. Those are all ingredients that are found in very common household foods and goods. And, um, infants would be exposed to them at a much higher level than is included in the injection. And as it's been said before, no preservatives. And, um, and also, uh, no, um, uh, aluminum. Um, in addition, I think as someone who's had many of these conversations, when we do provide balanced education to families on, um, risks and benefits, it is often true that families do, um, choose to pursue a, a vitamin K injection. Um, and I think it is important to share all of the details related to that. So just here also to answer any pharmacy related questions and I'll, uh, yield my time.

Hi, my name is Joyce Mitchell. I'm speaking from Cedar Hills, Utah. I'm a mother and a grandmother, and I did work for a midwife, a licensed midwife for years, and they always kept a consent refusal form in the record of the parents, um, concerning vitamin K. And I think that the question is not whether vitamin K is good or not, but if it can be used to throw parents in jail. As we've heard, vitamin K is being, the consent or refusal is being used in Illinois to report parents to DCFS and Pennsylvania. Charges of murder have occurred in against parents who signed a simple informational document that putting babies to bed on their backs to sleep is safer. After their baby died of sids, they were charged with manslaughter because they put their baby on his stomach to go to bed because, and they had signed that document and the signing of the document was the evidence that they needed to throw them into jail. And, uh, even an, the executive director of First Candle, a nonprofit that educates parents about safe sleep practices, said there is no law against placing a baby on his or her stomach to sleep. How can they charge this family with involuntary manslaughter is completely baffling to me. So there were good intentions and then they were used against parents. So I would like to see, uh, some kind of disclaimer in the, in the law or some wording in the law that would, uh, disallow accusations of child abuse.

Hi, I'm Dr. Robin Les, and I'm here, uh, speaking for myself as a neonatologist, uh, having parents decide, uh, to refuse medications that we use frequently, um, and in the best interest of infants is, is quite disheartening. Um, we want what's best for the babies, but we know parents want what's best for their babies too. We know that this is not something, um, devious or, um, uh, folks that are trying to hurt their babies. They're trying to help their babies, and I understand that, um, shots can be scary for the babies. I take care of. I work in a, a newborn ICU, I'm a neonatologist, and just being in the NICU is a, is a terrifying experience for parents. Um, and it's really hard for them to, uh, watch their baby being taken care of, but also just understanding, um, that lots of things are happening that they don't understand. I think, um, when I try to explain issues with vitamin K or with vaccines to moms and dads, um, I liken it to wearing a seatbelt. Um, we all wear seat belts in the car, or we are supposed to, and we can even get tickets if we don't, but a seatbelt doesn't prevent you from getting in an accident. Um, your car can still be hit, you can still hit another car, but it will decrease the chance of you dying. Um, and it will decrease the injury that you receive. Most likely nothing is a hundred percent and vitamin K in and of itself is not a hundred percent either. Um, but for those babies that return to our hospital, to the children's hospital here in Salt Lake City with, uh, terminal brain bleeds, uh, where their, their life is shortened, um, to just a few days, it, um, it really strikes us as something that if we can prevent, um, we want to do everything we can to, uh, let our parents know that they also can prevent that. I agree with putting all the information. Uh, the, uh, box warning by the FDA is, um, as, uh, a previous speaker mentioned, um, uh, a little bit dated and it does, um, it does involve the Rapid Administration IV of vitamin K as Carly mentioned. Um, but we do give the dose, um, intramuscularly usually we don't give it subcutaneously, but I think it's important to put that, all that information, it's good to have the risks and benefits, um, of all of the medications that we use, uh, in our newborns. Um, and I'm happy to answer questions.

Thank you Mr. Chair. I'd like to adopt fourth sub in my name.

Yeah. It removes the direct entry midwifery per our conversation, um, as well as removes the form that Representative Shelley was talking about.

I I was just actually over here doing my read through the thing and, and I think that, um, it addresses the concerns that, that both the good representatives brought up about talking about risks and benefit as well as how do you police something that's unpleasable. Um, and so I, I find that to be favorable and it actually improves the policy.

I'd like to move that we adopt House Amendment one also in my name.

Broke the drafter when we were rushing through the earlier sub, so this makes it do everything I just said it was supposed to do.

Between my readers and my, whichever ones. Would you all like me to read a to you so I know what it says? Provide a full and clear explanation of the risks and benefits of Vitamin K administration and the risks of possible adverse outcomes for a newborn. That does not receive vitamin K. And then it's just the next is a parent may decline to consent to the administration of vitamin K, but no form. So I absolutely, and thanks to the drafters who are doing quick typing to get there.

Yeah. Um, I apologize to the drafter who I know is listening. I'm sorry that we broke you. You're a wonderful drafter.

Go ahead. Uh, thank you. Uh, Mr. Rice chair. I would just like to make a motion that we pass Senate bill 1 74 substitute as amended out with a favorable recommendation. That motion is an order. Would you like to speak to it? I mean, I think, I think the bill as it sits now is pretty simple. Um, and I think it gets to what we want to get to. I think, um, I think there is more benefit here in focusing on the folks giving the education and less benefit. And, and at times, maybe even something counterproductive when you start to say in statute what the parent has to do. Um, I know that commit, you know, clinicians are committed to giving good information as we, we said, this kind of makes it clear that we really do want that to happen. So, um, I support this bill.

No, as, as I, um, alluded to a little bit when I came in, I do think the conversations are honestly some of the best part of what we do up here is that we learn from each other's perspectives and have thoughts that we didn't have. And I, I am really grateful for the, the thoughts that were brought into this as well as the changes that were made because I, I do think we all have the same goal and that is helping folks live the way they wanna live and, and helping them be healthy and doing so. So,

I'll just say you, you only have to have it happen once where you go in 'cause the mom brings her little baby back in to the urgent care a couple of days in 'cause she thinks she thinks something is wrong with the circumcision and open the diaper and see the baby's penis and abdomen and thighs just covered in blood, um, to, not because anything was done wrong about the circumcision, but just 'cause the baby couldn't clot and then you remember that a long time. So, uh, that's my sum. Thank you.

Truly thank you all.

Uh, so I would, uh, move to delete entitled and body and replace Senate bill one 70 with substitute number two Senate bill one 70.

Um, yes. This was actually brought to my attention, um, by the good Senator Stratton when we were in committee that there was some pieces of the wording that did not indicate, uh, what I thought was happening was happening in the way that we wanted it to. And, and that was that every family that was delivering a baby would receive education about what Vitamin K deficiency bleeding is and why it was important. And the language of the bill did not reflect that. So this adds that in. It also added in a little bit of language that came from our nurse practitioner colleagues to make sure that we were accurately reflecting what they could and couldn't do.

Thank you Mr. President ProAm, it's an interesting time to be involved in caring for folks. There's a lot of, um, speculation and, and folks who are uneasy about the practice of medicine and, and about vaccines and medications. And I don't dispute that that's appropriate. People should wonder about things especially coming out of kind of a crazy time that we've all experienced coming into and out of the pandemic. One of the things that's come out of this that makes me nervous and also sad is that there's an increasing number of parents who are re uh, refusing a vitamin K injection when their babies are born. In fact, in the Intermountain Healthcare Hospital system, statewide, in their regular well baby nurseries, it's gone from about a 1% refusal to 6% refusal. And this is a vitamin. This isn't a vaccine, this isn't a medication, this is a vitamin. And the reason this vitamin is important is that it kicks off what we call the clotting cascade in your body. And if you don't have a, the ability to clot, you all might imagine if you ever know anyone who's been on Coumadin or Warfarin or any of these other clotting meds, you bleed easily, you bruise easily, you can't stop bleeding on your own. Well, childbirth is a pretty beautiful process, but it's also pretty traumatic if we, any of us who have experienced it or have watched it, there's some squishing and some things that happen as that baby is delivered and it is traumatic to the baby and without the ability to clot, it can lead to things like intracranial hemorrhages or bleeds within the brain, is what that means. I can tell you I've been trying to get data pulled from across our hospital systems to see what the numbers and increases have gone up and there's ongoing data, data collection. But I can tell you that multiple of my colleagues and I have seen intracranial hemorrhages or bleeds in babies' heads for the first time in our careers. There is definitely something happening there. I've seen two. And the last one that I saw was a family down at the Lehi Primary Children's. And the dad was so sad and he was so remorseful and he said he shared, I just wish I would've known what I was refusing and what it could lead to. So what this bill does is it sets up a, a kind of a process in place whereby every hospital where children are born or nurse midwifery sort of setting where babies are delivered will either administer the vitamin K or arrange for it to be administered. It also sets up, uh, the opt out option for families. As long as they've been educated and they want to opt out, that's okay too. But I think with something like a bleed in the brain that is undoable, you don't go back to what you were before. And once it's done, it's done. It's so important that we make sure everyone is educated and certainly they still have the right to opt out, but they've at least been educated when they do so. So I looked at other states and what they were doing. Some states, um, don't, uh, one of them, I think it was Florida, if you didn't, if you refused the vitamin K, they had an automatic DCFS referral, which I didn't think that was the right strategy. And this just felt like a good middle ground. Make sure we've got folks educated, make sure there's an optout procedure and let's set it out so people know going into it. But that I'm certainly open to. Any questions?

Thank you Mr. President ProAm. With that, I would call the question And the question is, shall second substitute Senate bill one 70?

Thank you Mr. President Pro Tim. Uh, this bill, which I'm not aware of any opposition to, would, um, require the Disability Law Center,

Thank you Mr. President. Um, yesterday we talked about this bill and I, I took a little bit of a temperature and a pulse check on the room and realized that perhaps I needed to think a little bit more about the policy because there was some kind of unease. Uh, and so the substitute I would like to, um, move forward now, which is third substitute only requires education on what Vitamin K administration to newborns does and also offers, uh, an opt out policy. Um, if, if anyone would like to discuss that, otherwise I'd, I'd love to make a motion to substitute that.

Yeah, I think just to help educate and I've learned a lot from my own readings on this that I perhaps didn't know the skepticism and nerves around pharmaceutical products and vaccines that have arisen over the past decade. You know, I do understand why people are having nerves about them. I think that in the establishment, we at times have not done the best job about educating and also about allowing people to form their own opinions. And something that fell into that is this vitamin K administration that is given to newborns shortly after they're born. It's a vitamin. Uh, I know Intermountain Healthcare hospitals don't even have a preservative in it anymore. It's a vitamin. And what vitamin K does, we need it as humans to clot blood. It's as simple as that. And so it's administered to prevent life threatening and life altering bleeds such as intracranial hemorrhages, which is bleeding into the brain. Unfortunately, you can't get it through an oral dosing. It mostly comes from plants other than from this type of administration. It's not real present in breast milk, unfortunately. So breastfed babies also need this little extra boost since the increasing declines that we've seen. And since 2018, we've seen decline rates from 1% to now 6% in our infant populations.

Absolutely. I would love that. Um, my, my biggest hope out of this is that from the two patients I've seen in the last year who had bleeds into their brain, and I'd never seen it before in my career, one really stuck with me. And that was the father who said, I really wish I would've known what I was turning down. And so I would like this education so that parents can make informed, educated parental choice. I'm always going to support that, but the education piece is so crucial. So now that I've re blathered on about something I'm clearly quite passionate about, let's circle it for that fiscal note and to be continued on. Third read, I don't think we can. Does that work?

And I promise not to blather on this

Senator Wilson, Motion to circle sponsors off the floor.

Senator Wilson. Motion To circle sponsors off the Floor. Motion to circle. All

Uh, with that I would call a question. The question is, shall third substitute Senate Bill one 70 pass Roll call vote.

Senator Vickers. Baldy. Lewin Aye. Bramer Bus Cullimore. Esca Aye. Fillmore No. Grover Harper Hankins. Ipson Aye. Johnson Quan McKay. Mikel Milner Musselman Owens Pitcher Plum Aye. Rebe Aye. Sandal Stevenson Stratton Vickers Weiler Wilson Winterton Wilson.

Thank you. Motion Unci. Second substitute SB 2 0 5. The motion is to encircle second substitute Senate Bill 2 0 5, which has a fiscal note.

I've said enough.

Senator Editors Baldy. B Lewin Brammer Bus Comore. Escamia Fillmore Grover Harper Kins. Ipson. Let's Get down to nine. Ipson Johnson Wan McKay. Mikel Milner Aye. Musselman Owens Pitcher Plum Rebi Sandal Stevenson Stratton Vickers. Vickers. Weiler Wilson. Aye. Wilson Winterton,

Senator Pitcher To Concur.

Yes. This made some slight fixes to, uh, the process to,

Uh, this bill relates to the administration of vitamin K. Uh, when a, a newborn, uh, is born that helps protect the baby against blood clots. The bill's had a bunch of substitutions made to it so that it doesn't have any requirement on the parents at all. It's directed towards the staff in the hospital who is providing the information to the parents and their newborn so that they can have accurate information about how the vitamin K can help protect their child against bleeding. Thank you, Mr. Speaker.

Thank you Mr. Speaker Motion. UNC Circle, uh, Senate bill 3 0 4.