Neonate with blood in the nappy: look beyond the cracked nipples!

Authors: Fatimah Aliyu / Editor: Liz Herrieven /  Codes:  / Published: 27/07/2021

Rob, a 15-day old neonate has been brought to ED by his mum, Lucy, after she noticed some streaks of blood in his nappy. He was born at 39 weeks by spontaneous vaginal delivery after an uncomplicated pregnancy and has been exclusively breast fed since birth.

Observation: HR 157/min, RR 47/min, Oxygen saturation 100% in air, Temperature 36.70C

• How will you approach this case?
• What are the red flags you need to consider?
• Are you going to carry out any investigations? If yes, which investigations would you consider?

Blood in the nappy of newborn babies is a common problem with causes ranging from benign to life threatening. 

Common causes include:

• Physiological vaginal bleeding in girls (mini-periods)

This can be seen as visible blood in the nappy in about a third of female neonates but can also occur microscopically.

The condition is benign and usually resolves on its own, but any vaginal bleeding lasting longer than a week, or appearing for the first time after that period, requires further assessment to rule out pathological conditions or even NAI.

• Milk protein enterocolitis

This presents most commonly between the first month and first year of age. It can be seen in both breast- and bottle-fed infants. The child looks otherwise well, although may have a history of frequent vomiting, frequent loose stools, fussy feeding and lots of crying, often with drawing up of the knees.

It is thought to be caused by a non-IgE-mediated hypersensitivity reaction to certain specific dietary antigens. Typically, the blood is bright red, often with mucus, in most stools. Inspection of the nappy area may reveal skin excoriation.

Once other causes, such as infection, intussusception, etc., have been excluded, the management of allergic colitis is by dietary antigen exclusion with either a hypoallergenic milk formula (hydrolysed cows milk protein or even amino acid-based formulae are preferred to soya-based varieties) or maternal dietary antigen exclusion.

In severe cases, the child will look unwell with features of Necrotizing Enterocolitis (NEC)

• Perianal/Rectal Fissure

This is typically related to the passage of large and/or hard stool. Not commonly seen in the neonatal period, but always ask about stool consistency.

• Urate crystals

These are fairly common in the first few days of life and are a normal finding. They can look orange or red. In older children they may be a sign of dehydration. 

• Dermatitis or nappy rash

If severe, there may be bleeding points on the skin of the nappy area. Good attention to hygiene, having some nappy-free time, and using nappy creams can help. 

• Swallowed maternal blood

Swallowed maternal blood may appear in a neonate’s stools, for example after an antepartum haemorrhage. In this case it is usually dark in colour. Many texts quote cracked nipples as another cause of blood in a baby’s stools, but this isn’t often seen in practice. To be a problem, there would have to be a significant amount of blood swallowed, and it would appear in the nappy to be dark in colour, similar to melaena. A more common result of cracked maternal nipples is blood in the otherwise milky vomit of a well, breastfeeding baby. A urine dipstick can be used to test for microscopic blood in maternal milk. 

Life threatening causes:

• Necrotizing Enterocolitis

This condition occurs when bacteria invade the wall of the intestine and cause inflammation and, in severe cases, can cause intestinal perforation. It commonly occurs in preterm neonates but can also be seen in term neonates. The baby will appear unwell. Clinical features may include bilious vomiting, abdominal distention, or discolouration of the abdomen, as well as bloody stools. NEC is a medical emergency requiring resuscitation and urgent surgical input.

• Malrotation with volvulus

These are two distinct conditions. Malrotation occurs in utero. Around the tenth week of pregnancy, the bowel moves back into the abdomen and coils up to fit into the limited space there. If the bowel does not coil up in the correct position, this is called malrotation. A baby with malrotation may not have any symptoms, however, due to its abnormal position, the duodenum may kink or twist, causing a blockage. Clinical signs of this may include short bouts of crying which will suddenly stop; parents may describe the baby as being unsettled. There may also be a history of the child passing infrequent stools (as food cannot pass through the obstructed gut). There may be bilious vomiting as well as blood in the nappy. This is also a medical emergency but remember, you might be reviewing the child at the time the obstruction is temporarily relieved, hence the need to take a good history.

• Hirschsprung enterocolitis

This is a condition that develops due to an abnormality of the developing large intestine, where a segment of the gut is missing neurons and is unable to dilate to allow passage of stool. Hence, it remains constricted with a dilated segment above it. In the neonatal period, it can present with abdominal distention, vomiting and poor feeding. Hirschsprung-associated enterocolitis (HAEC) is a complication of Hirschsprung disease which occurs when there is bowel inflammation due to excessive bacteria proliferation in the gut caused by Hirschsprungs disease. There may be a history of delayed passage of meconium of up to 48 hours after birth, abdominal distention, and/or bilious vomiting (remember bilious, bright green, vomiting always equals obstruction in a newborn).

• Haemorrhagic disease of the newborn due to Vitamin K deficiency

Newborns have minimal vitamin K reserves in their liver at the time of delivery and are not able to synthesize vitamin K due to a sterile gut. Hence, they are at risk of developing haemorrhagic disease of the newborn. This condition can present anytime from within the first 24 hours up to 12 months of age3. Babies can present with GI bleeds, cephalhematoma or catastrophic intracranial bleeds. Preterm babies are at a greater risk of developing vitamin K deficiency-related bleeding.

• Disseminated intravascular coagulopathy

Disseminated intravascular coagulopathy (DIC) is a rare but serious condition that causes abnormal blood clotting throughout the bodys blood vessels. Consumption of clotting factors during this process causes bleeding elsewhere. DIC can be triggered by, amongst other things, infection or injury. Babies will be unwell with a fever, rash, GI bleeding, bleeding from the mouth or nose, and may present in shock.

• Infectious Colitis

Infections like Salmonella, Shigella, E coli, and Yersinia can cause bloody stool in neonates. They are usually self-resolving in the well child but can cause dehydration.

Approach to the new-born with blood in stools

With so many differentials to consider, it is worth taking a history in a systematic way.

• Antenatal and pregnancy history

Including maternal medication use during pregnancy: aspirin and phenobarbital are well-known causes of coagulation abnormalities in neonates.

• Birth history

Gestation at delivery: NEC is more common in preterm neonates.
Was there any need for resuscitation after delivery? Mechanical ventilation is associated with neonatal stress-gastritis.

Was vitamin K given at birth? If yes, was it oral or intra-muscular? If oral, was the course completed (oral Vitamin K is not as protective as IM in protecting against haemorrhagic disease of the new-born). 

Any history of antepartum haemorrhage? This might indicate swallowed blood.

Any risk factors for neonatal sepsis? Maternal pyrexia, maternal group B strep colonisation, premature or prolonged rupture of the membranes all worth asking about?

• Feeding

How is the baby fed? Breastfed infants are at a risk of vitamin K deficiency (formula milk is supplemented) ⁴
Cows milk or soya fed babies are at increased risk of colitis.⁵
Has the mother got cracked nipples?
Is the baby gaining weight well and thriving?

Is there bilious vomiting? This is a red flag and calls for urgent assessment.

Family history

Any history of food intolerance?
Any bleeding disorders in the family?

RED FLAGS on examination:

Remember to take the nappy off and have a look! There might be skin excoriation in the perianal region, which this may be a sign of colitis!

If in doubt- REFER to paediatrics.

Babies in this age group can sometimes be difficult to assess.

Investigations

This depends on the history and examination findings.

Investigations are not always needed if a clear cause is found from the history.

Investigations to consider if indicated:

• Full blood count
• Blood culture
• Stool culture
• Liver function tests
• Coagulation profile
• Abdominal Xray

Further management may include:

• Fluid resuscitation if the baby appears shocked
• Analgesia if in pain
• FFP for coagulopathy or massive bleeding
• Urgent surgical opinion if unwell and a surgical cause of bleeding is suspected
• Intravenous antibiotics for sepsis or NEC
• Vitamin K (give intravenous for a rapid response)
• Therapeutic trial of hypoallergenic formula in allergic colitis eg: Peptijunior, Neocate or Nutramigen

Learning points

• Have an open mind: dont assume blood in the nappy is benign  
• Systemic approach to history taking and examination: it is easy to miss bits of the history without a systemic approach, especially if you are not used to taking neonatal histories
• If in doubt, ask! Children in this age group can be difficult to assess. Refer to paediatrics if in doubt  

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References

1. Romano, C., Oliva, S., Martellossi, S., et al., (2017). Pediatric gastrointestinal bleeding: Perspectives from the Italian Society of Pediatric Gastroenterology. World journal of gastroenterology, 23(8), 13281337.
2. Huber A. [The frequency of physiologic vaginal bleeding of newborn infants]. Zentralbl Gynakol. 1976;98(16):1017-20. German. PMID: 973490.
3. Holla RG, Prasad AN. Haemorrhagic Disease of new born presenting as Subdural Hematoma. Med J Armed Forces India. 2010 Jan;66(1):86-7.
4. Chalmers EA. Neonatal coagulation problems. Arch Dis Child Fetal Neonatal Ed 2004; 89: F475-8.
5. Xanthakos SA, Schwimmer JB, Melin-Aldana H, et al. Prevalence and outcome of allergic colitis in healthy infants with rectal bleeding: a prospective cohort study. J Pediatr Gastroenterol Nutr. 2005 Jul;41(1):16-22.