Neonatal lower gastrointestinal bleeding

Background

Acute GI bleeding in children carries low mortality and is often a self-limited condition in infants

Clinical Features

• Bloody stool
• +/- additional features of underlying condition
• +/- signs of anemia, shock if significant bleed

Differential Diagnosis

• Emergent: typically do not present with isolated hematochezia
  • Necrotizing enterocolitis
  • Malrotation with volvulus
  • Hirschsprung's disease
  • Coagulopathy (see other bleeding symptoms (cephalohematoma, mucocutaneous bleeding, petechiae)
    • Vitamin K deficiency (if not given after delivery)
    • Maternal thrombocytopenia
    • DIC
  • Infectious colitis
  • FPIES

• Other conditions
  • Swallowed maternal blood (e.g. from chapped nipples)
  • Milk protein enterocolitis
  • Perianal/rectal fissure

Evaluation

• Examine stool directly and test for blood
  • Apt test: distinguishes maternal versus infant's blood (fetal Hgb is resistant to alkali and stays pink, adult Hgb hydrolyzed by alkali--> yellow/brown)
• Evaluate for underlying emergent etiology if sick or suggestive presentation
  • abnormal abdominal exam (distension, tenderness, abnormal bowel sounds): abdominal plain film

Management

• Treat underlying condition, resuscitate prn
• If well-appearing with low-moderate blood and suspect milk or soy protein induced colitis, trial eliminating milk/soy are well appearing, stools with low-moderate blood, trial eliminating milk and soy from the diet

Disposition

• Dependant on degree of bleeding and underlying etiology; most can be discharged

References

• https://pedemmorsels.com/neonate-with-bloody-stool/
• https://www.uptodate.com/contents/lower-gastrointestinal-bleeding-in-children-causes-and-diagnostic-approach