Know that bloody stools can be an anxiety-provoking event to new parents, but is most often a benign finding in an otherwise well-appearing newborn baby. Know when to intervene and when to observe

Author: Laura Hufford, MD

What to Do - Interpret the Data

In newborns, one of the most common causes of blood in the stool is swallowed maternal blood. This occurs either during the delivery process or during breastfeeding if the mother's nipples are cracked and bleeding. If a maternal source is considered, then one can perform the Apt test to determine the origin of the blood. In this test, stool is mixed with water and centrifuged. Sodium hydroxide is added to the supernatant. If the blood is from the mother, the adult hemoglobin will denature and the sample will turn light brown. However, if the source of the blood is the infant, the sample remains pink because fetal hemoglobin is resistant to denaturation.

Anorectal fissures are another very common cause of rectal bleeding in children younger than 12 months. These fissures are usually seen upon close examination of the perineal skin and the anal canal. Often, they are small and caused by the passage of hard stool and resolve once the underlying constipation has been addressed.

Another common cause for blood in an infant's stool is food allergies. The top common allergens are cow's mild products and soy. Milk allergies occur in approximately 2% to 3% of infants, and it is typically outgrown by the age of 3 to 5 years. Symptoms include loose stools, vomiting, gagging, irritability or colic, and skin rashes. Avoiding milk-containing products is the treatment, and since January 2006, all U.S. food makers must clearly state on the package labels whether the foods contain milk or milk-based products. For infants, using a soy-based formula will sometimes work, but some infants may require using a hypoallergenic formula that contains predigested proteins.

Bloody stools in infants can also be the presenting sign of life-threatening conditions. One serious condition that should be considered in newborns is necrotizing enterocolitis (NEC). Associated symptoms can be apnea, abdominal distension, poor feeding or lethargy. Additionally pneumatosis intestinalis, air within the bowel wall, may be seen on radiographs. Although the etiology of NEC is unknown, it is likely multifactorial with bacterial overgrowth, enteral feeds, and hypoxia acting on immature intestinal mucosa to cause mucosal injury. The process continues, causing transmural and mucosal necrosis, and in severe cases, it causes perforation of the bowel wall. The incidence of NEC increases with lower gestational age; however, nearly 10% of cases occur in term infants. Treatment includes discontinuing all enteral feeds, intravenous antibiotics and supportive therapy. If perforation is suspected, then laparotomy and bowel resection may be indicated.

Another life-threatening cause of bloody stools in an infant is malrotation with midgut volvulus. Early in gestational development the gastrointestinal tract rapidly grows and protrudes into the yolk sac. The intestine then rotates 270 degrees in a counterclockwise fashion and returns into the abdominal cavity. Once inside the abdominal cavity, the bowel is fixed into place with the proximal portion of the bowel attached at the ligament of Treitz. If normal rotation fails to occur, a thin vascular stalk anchors the small bowel, which places the intestine at risk for midgut volvulus, torsion around this stalk, and subsequent bowel obstruction and ischemia. If torsion occurs, the patient may initially present with bilious emesis and abdominal distension. As the ischemic bowel begins to die, bloody stools, perforation, sepsis, and death can occur. Thus, early detection of malrotation with upper gastrointestinal contrast study is imperative. However, if an infant presents with bilious emesis and abdominal distension, they need no imaging and should undergo emergent operative management.

Suggested Readings

Fonkalsrud E.Rotational anomalies and volvulus. In:O’Neill JA,etal,eds.Principles of Pediatric Surgery. St. Louis: Mosby; 2003:477.
Gosche J, Vick L, Boulanger SC, et al. Midgut abnormalities. Surg Clin North Am. 2006;86: 285–299.
Liu N, Wu AH, Wong SS. Improved quantitative Apt test for detecting fetal hemoglobin in bloody stools of newborns. Clin Chem. 1993;11 (Pt 1):2326–2329.
Luig M, Lui K; NSW & ACT NICUS Group. Epidemiology of necrotizing enterocolitis–Part II: Risks and susceptibility of premature infants during the surfactant era: A regional study. J Paediatr Child Health. 2005;41(4):174–179.
Maayan-Metzger A,Itzchak A,Mazkereth R,etal.Necrotizing enterocolitis in full-terminfants: Case-control study and review of the literature. J Perinatol. 2004;24(8):494–489.

Book Source Details

• Book Title: Avoiding Common Pediatric Errors
• Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
• Year of Publication: 2008
• Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Avoiding Common Pediatric Errors Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7489-6

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