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Bloody Neonatal Diaper
CASE REPORT
BloodyNeonatal Diaper From the Department of Emergency Medicine, the Medical Collegeof Pennsylvania and Hahnemann University, Philadelphia, Pennsylvania. Receivedfor publication October 31, 1995. Acceptedfor publicagon November 9, 1995. Copyright © by the American College of Emergency Medicine.
Ronald P Guritzky, MS Gail Rudnitsky, MD
As part of the ongoing effort to minimize health care expenses, mothers and newborns are being discharged after shorter hospital stays. Problems that previously would have been noticed in the hospital nursery are now being seen in the emergency department. We report the case of a 1-day-old infant who was brought to our ED with grossly bloody stool. An Apt test 1 was performed to determine whether the blood was of infant or maternal origin. After determining that the blood was the infant's, we transferred the child to a pediatric specialty center, where a diagnosis of necrotizing enterocolitis was made. [Guritzky RP, Rudnitsky G: Bloody neonatal diaper. Ann Emerg MedMay 1996;27:662-664.]
INTRODUCTION As part of recent efforts to cut health care costs, infants are spending less time in the newborn nursery. This creates no problem for the healthy infant, but because many neonatal problems do not show up on the first day of life, those with hidden problems are at increased risk. Many of these infants present to the emergency department. Although emergency physicians have always treated neonates, until recently they did not frequently see children younger than 3 days of age. Today, the emergency physician must be prepared to deaI with an additional set of problems that were until recently uncommon outside the hospital nursery.
CASE REPORT A 1-day-old female infant was brought to the ED by her parents with a complaint of three episodes of bloody stools during the preceding 45 minutes. This full-term infant had been born the previous morning in an uncomplicated vaginal delivery. The gravida 5, para 5, 31-year-old mother had had good prenatal care. She denied drug use but admitted to smoking cigarettes. Her pregnancy had been complicated by poor weight gain and a urinary tract infection. The
662
ANNALS OF EMERGENCY MEDICINE
27:5 MAY
1996
BLOODY NEONATAL DIAPER
Guritzky & Rudnitsl~y
infant's birth weight was 2.9 kg. Because the infant's siblings at home had chicken pox, the infant was given immunoglobulin for passive prophylaxis before discharge. Mother and child were discharged on the afternoon of the first full postpartum day. At home, the mother noticed that the child was sleeping a lot and not taking her bottle (Enfamil with iron). That evening, the mother found bright red blood mixed with stool in the diaper. There was no history of excessive crying or vomiting. The infant had two further episodes of bloody stool and was then brought in for evaluation. On examination, the patient was active and not crying. Her vital signs were blood pressure, 79/40 mm Hg; pulse, 140; respirations, 44; and rectal temperature, 37.3°C. Physical examination was unremarkable except for an anal fissure. Her diaper was full of brown stool mixed with bright red blood. An Apt test, performed on the diaper contents, showed the blood to be of fetal origin. A feeding tube was inserted orally into the patient's stomach. The gastric contents were negative for blood. Her WBC count was 6,600 cells/BL with 24°£ hands, 42% neutrophils, 330£ lymphocytes, and 1% monocytes. Hemoglobin was 17.1 g/dL, hematocrit 49%, and platelets 195,000/BL. RBC morphologic analysis revealed slight anisocytosis, slight poikilocytosis, slight polychromasia, and slight macrocytosis with an occasional teardrop-shaped cell. Prothrombin time was 12.9 seconds, and partial thromboplastin time was 50.8 seconds. Blood and stool were also sent for cul-
tures, which were negative. Abdominal fiat plate radiography was ordered (Figure); its results were interpreted to be consistent with pneumatosis intestinalis without free air. The patient was transferred to a pediatric specialty center for further workup, where a diagnosis of necrotizing enterocofitis (NEC) was made. The child was given nothing by mouth, and antibiotics were started. On the third hospital day, both the heme-positive stools and the pneumatosis intestinafis resolved. Antibiotics were continued for 7 more days. The infant was then started on formula. She tolerated this well and was discharged home on hospital day 14. DISCUSSION
Although information on neonatal bloody stools is common in the neonatology literature, it is lacking in the emergency literature. This is not surprising because, until recently, the only place such a patient was likely to appear was the hospital nursery. The differential diagnosis for neonatal gastrointestinal bleeding includes swallowed-blood syndrome, which occurs when an infant swallows maternal blood, either during delivery or from a fissure on the mother's nipple while nursing. Swallowed blood usually appears in the stool in the second or third day of life. ~ It is important to be able to determine the blood's origin quickly. An easy way to do this is the Apt test. 2,3 A sample of bloody stool
Figure. A, Abdominal flat plate; and B, l@ lateral decubitus consistent with pneumatosis intestinalis.
MAY 1996
27:5
ANNALS OF EMERGENCY MEDJC/NE
66 3
BLOODY NEONATAL DIAPER Gufitzky & Rudnitsky
is mixed with water, and the resulting solution is centrifuged. The supernatant, which should be pink, is then mixed with 1% sodium hydroxide in a ratio of 5:1. If the blood is of maternal origin, the mixture turns yellowbrown after several minutes; fetal blood remains pink. This reaction occurs because fetal hemoglobin is more stable in basic solution than adult hemoglobin. It is important that the stool specimen be grossly bloody and not tarry. If only a blood-stained diaper is available, water and sodium hydroxide can be added directly to the stain, and the results will be apparent in several minutes. 4 More than half of neonatal gastrointestinal bleeds are idiopathic in origin and resolve within several days. 5 Sherman and Clatworthy 6 reported no deaths among 94 such patients and no positive findings on diagnostic testing. Other causes include congenital defects, coagulopathies, NEC, anal fissures, peptic ulcer disease, allergic colitis, and other rare problems, r Congenital defects include malrotation with volvulus (manifested by distention, vomiting, and irritability), Hirschsprung disease with enterocolitis, reduplicated bowel, and congenital heart disease. 4 Disseminated intravascular coagulation and hemorrhagic disease of the newborn can cause gastrointestinal bleeding. In such cases, however, there is usually bleeding from other sites. Prothrombin time, partial thromboplastin time, and fibrinogen determinations should be ordered if a coagulopathy is suspected. If hemorrhagic disease of the newborn is suspected and it cannot be determined whether the infant received vitamin K at birth, 1 mg vitamin K should be given, s NEC is most commonly found in premature and low-birthweight infants, although 10% of cases occur in full-term infants. It is the most common gastrointestinal emergency in neonatal ICUs in most countries of the world, 9 and it is more common in formula- fed than breast-fed infants. Although the cause is unknown, current theories implicate ischemic injury, microbial agents, too rapid feeding protocols, the neonate's immunologic immaturity, and the absence of secretory IgA from formula. The actual cause is probably some combination of a subset of these factors. Initial symptoms almost always include abdominal distention and gastric retention. A radiogram may show pneumatosis intestinalis, which is diagnostic. Initial therapy is supportive and includes prevention of shock and correction of acid-base and electrolyte imbalances. NEC can progress to a perforation and peritonitis, which may be indicated by red streaks on the abdomen. In this case, resection of the necrotic bowel is necessa~ lo,11
664
Rectal or anal fissures simply require observation. Allergic colitis as a cause of gastrointestinal bleeding must be confirmed either by endoscopy with biopsy or by cessation of the symptoms after the suspected allergen is removed and recurrence after it is reintroduced. Possible but rare causes of bloody stool in the neonate are infection (including 5higella and Salmonella), Meckel diverticulum, gastroenteritis, intussusception, and ulcer. 2,3,5,s Recent and anticipated changes in US health care systems have increased the diversity of pathologies presenting to the ED. This is also true in the area of neonatology The rapid discharge of the "healthy" mother and child means that those infants with problems that evidence themselves after the first 24 hours may be brought to the ED. The neonate may present with such conditions as hyperbilirubinemia, failure to thrive, vomiting, a fistula, or congenital heart disease. This paper presented the case of a newborn arriving in the ED with gastrointestinal bleeding. Although physicians who staff hospital nurseries have experience with this potentially lethal condition, emergency physicians do not. The emergency physician must be prepared to deal with these cases as well as other neonatal emergencies. REFERENCES 1. Apt L: Melena neonatorum:An experimentalstudy of the effect of oral administration of blood on the stools. J Pediatr 1955;47:1-5. 2. Gotoff SP:The fetus and neonatal infant: Digestive system, in Beh~manR {ed): Nelson textbook of pediatrics, ed 14. Philadelphia: WB Saundors,1992:487. 3. Halliday HL, McClure G, Reid M: Handbookof Neonatallntensive Care. London:Bailliere Tindall, 1981:24, 209. 4. Apt L, DowneyJr WS: "Melena" neonatorum:The swallowed blood syndrome.J Pediatr 1955;47:6-12. 5. HodsonWA, TruogWE: Critical Care of the Newborn, ed 2. Philadelphia: Saunders,1989:96-£7. 6. ShermanNJ, ClatworthyJr HW: Gastrointestinalbleeding in neonates:A study of 94 cases. Surgery1957;62:614-519. 7. Harrison MR, deLerimierAA: Gastrointestinalhemorrhage,in PascoeDJ, GrossmanM (eds): Quick reference to pediatric emergencies, ed 3. Philadelphia: Lippincott, 1984:337-343. 8. GomellaTL (ed): Neonatolog~"Basic Management, On-CarlProblems, Disease, Drugs-1988-I989. Norwalk, Connecticut:Appleton & Lance, 1988. 9. KosloskeAM: Epidemiologyof necrotizing enterocolitis.Acta Podietr Supp11994;296:2-7. 10. Cotran RS, KumarV, Robbins SL: RobbinsPathologic Basis of Disease, ed 4. Philadelphia: WB Saundars, 198£:890. 11. Silber G: Lower gastrointestinal bleeding. PediatrRev 1990;12:85-93.
Reprint no. 47/1/72098 Address for reprints: Gail Rudnitsky,MD The Medical Collegeof Pennsylvaniaand HahnemannUniversity Department of EmergencyMedicine 3300 HenryAvenue Philadelphia,Pennsylvania19129
ANNALS OF EMERGENCY MEDICINE
27:5
MAY 1996
BloodyNeonatal Diaper From the Department of Emergency Medicine, the Medical Collegeof Pennsylvania and Hahnemann University, Philadelphia, Pennsylvania. Receivedfor publication October 31, 1995. Acceptedfor publicagon November 9, 1995. Copyright © by the American College of Emergency Medicine.
Ronald P Guritzky, MS Gail Rudnitsky, MD
As part of the ongoing effort to minimize health care expenses, mothers and newborns are being discharged after shorter hospital stays. Problems that previously would have been noticed in the hospital nursery are now being seen in the emergency department. We report the case of a 1-day-old infant who was brought to our ED with grossly bloody stool. An Apt test 1 was performed to determine whether the blood was of infant or maternal origin. After determining that the blood was the infant's, we transferred the child to a pediatric specialty center, where a diagnosis of necrotizing enterocolitis was made. [Guritzky RP, Rudnitsky G: Bloody neonatal diaper. Ann Emerg MedMay 1996;27:662-664.]
INTRODUCTION As part of recent efforts to cut health care costs, infants are spending less time in the newborn nursery. This creates no problem for the healthy infant, but because many neonatal problems do not show up on the first day of life, those with hidden problems are at increased risk. Many of these infants present to the emergency department. Although emergency physicians have always treated neonates, until recently they did not frequently see children younger than 3 days of age. Today, the emergency physician must be prepared to deaI with an additional set of problems that were until recently uncommon outside the hospital nursery.
CASE REPORT A 1-day-old female infant was brought to the ED by her parents with a complaint of three episodes of bloody stools during the preceding 45 minutes. This full-term infant had been born the previous morning in an uncomplicated vaginal delivery. The gravida 5, para 5, 31-year-old mother had had good prenatal care. She denied drug use but admitted to smoking cigarettes. Her pregnancy had been complicated by poor weight gain and a urinary tract infection. The
662
ANNALS OF EMERGENCY MEDICINE
27:5 MAY
1996
BLOODY NEONATAL DIAPER
Guritzky & Rudnitsl~y
infant's birth weight was 2.9 kg. Because the infant's siblings at home had chicken pox, the infant was given immunoglobulin for passive prophylaxis before discharge. Mother and child were discharged on the afternoon of the first full postpartum day. At home, the mother noticed that the child was sleeping a lot and not taking her bottle (Enfamil with iron). That evening, the mother found bright red blood mixed with stool in the diaper. There was no history of excessive crying or vomiting. The infant had two further episodes of bloody stool and was then brought in for evaluation. On examination, the patient was active and not crying. Her vital signs were blood pressure, 79/40 mm Hg; pulse, 140; respirations, 44; and rectal temperature, 37.3°C. Physical examination was unremarkable except for an anal fissure. Her diaper was full of brown stool mixed with bright red blood. An Apt test, performed on the diaper contents, showed the blood to be of fetal origin. A feeding tube was inserted orally into the patient's stomach. The gastric contents were negative for blood. Her WBC count was 6,600 cells/BL with 24°£ hands, 42% neutrophils, 330£ lymphocytes, and 1% monocytes. Hemoglobin was 17.1 g/dL, hematocrit 49%, and platelets 195,000/BL. RBC morphologic analysis revealed slight anisocytosis, slight poikilocytosis, slight polychromasia, and slight macrocytosis with an occasional teardrop-shaped cell. Prothrombin time was 12.9 seconds, and partial thromboplastin time was 50.8 seconds. Blood and stool were also sent for cul-
tures, which were negative. Abdominal fiat plate radiography was ordered (Figure); its results were interpreted to be consistent with pneumatosis intestinalis without free air. The patient was transferred to a pediatric specialty center for further workup, where a diagnosis of necrotizing enterocofitis (NEC) was made. The child was given nothing by mouth, and antibiotics were started. On the third hospital day, both the heme-positive stools and the pneumatosis intestinafis resolved. Antibiotics were continued for 7 more days. The infant was then started on formula. She tolerated this well and was discharged home on hospital day 14. DISCUSSION
Although information on neonatal bloody stools is common in the neonatology literature, it is lacking in the emergency literature. This is not surprising because, until recently, the only place such a patient was likely to appear was the hospital nursery. The differential diagnosis for neonatal gastrointestinal bleeding includes swallowed-blood syndrome, which occurs when an infant swallows maternal blood, either during delivery or from a fissure on the mother's nipple while nursing. Swallowed blood usually appears in the stool in the second or third day of life. ~ It is important to be able to determine the blood's origin quickly. An easy way to do this is the Apt test. 2,3 A sample of bloody stool
Figure. A, Abdominal flat plate; and B, l@ lateral decubitus consistent with pneumatosis intestinalis.
MAY 1996
27:5
ANNALS OF EMERGENCY MEDJC/NE
66 3
BLOODY NEONATAL DIAPER Gufitzky & Rudnitsky
is mixed with water, and the resulting solution is centrifuged. The supernatant, which should be pink, is then mixed with 1% sodium hydroxide in a ratio of 5:1. If the blood is of maternal origin, the mixture turns yellowbrown after several minutes; fetal blood remains pink. This reaction occurs because fetal hemoglobin is more stable in basic solution than adult hemoglobin. It is important that the stool specimen be grossly bloody and not tarry. If only a blood-stained diaper is available, water and sodium hydroxide can be added directly to the stain, and the results will be apparent in several minutes. 4 More than half of neonatal gastrointestinal bleeds are idiopathic in origin and resolve within several days. 5 Sherman and Clatworthy 6 reported no deaths among 94 such patients and no positive findings on diagnostic testing. Other causes include congenital defects, coagulopathies, NEC, anal fissures, peptic ulcer disease, allergic colitis, and other rare problems, r Congenital defects include malrotation with volvulus (manifested by distention, vomiting, and irritability), Hirschsprung disease with enterocolitis, reduplicated bowel, and congenital heart disease. 4 Disseminated intravascular coagulation and hemorrhagic disease of the newborn can cause gastrointestinal bleeding. In such cases, however, there is usually bleeding from other sites. Prothrombin time, partial thromboplastin time, and fibrinogen determinations should be ordered if a coagulopathy is suspected. If hemorrhagic disease of the newborn is suspected and it cannot be determined whether the infant received vitamin K at birth, 1 mg vitamin K should be given, s NEC is most commonly found in premature and low-birthweight infants, although 10% of cases occur in full-term infants. It is the most common gastrointestinal emergency in neonatal ICUs in most countries of the world, 9 and it is more common in formula- fed than breast-fed infants. Although the cause is unknown, current theories implicate ischemic injury, microbial agents, too rapid feeding protocols, the neonate's immunologic immaturity, and the absence of secretory IgA from formula. The actual cause is probably some combination of a subset of these factors. Initial symptoms almost always include abdominal distention and gastric retention. A radiogram may show pneumatosis intestinalis, which is diagnostic. Initial therapy is supportive and includes prevention of shock and correction of acid-base and electrolyte imbalances. NEC can progress to a perforation and peritonitis, which may be indicated by red streaks on the abdomen. In this case, resection of the necrotic bowel is necessa~ lo,11
664
Rectal or anal fissures simply require observation. Allergic colitis as a cause of gastrointestinal bleeding must be confirmed either by endoscopy with biopsy or by cessation of the symptoms after the suspected allergen is removed and recurrence after it is reintroduced. Possible but rare causes of bloody stool in the neonate are infection (including 5higella and Salmonella), Meckel diverticulum, gastroenteritis, intussusception, and ulcer. 2,3,5,s Recent and anticipated changes in US health care systems have increased the diversity of pathologies presenting to the ED. This is also true in the area of neonatology The rapid discharge of the "healthy" mother and child means that those infants with problems that evidence themselves after the first 24 hours may be brought to the ED. The neonate may present with such conditions as hyperbilirubinemia, failure to thrive, vomiting, a fistula, or congenital heart disease. This paper presented the case of a newborn arriving in the ED with gastrointestinal bleeding. Although physicians who staff hospital nurseries have experience with this potentially lethal condition, emergency physicians do not. The emergency physician must be prepared to deal with these cases as well as other neonatal emergencies. REFERENCES 1. Apt L: Melena neonatorum:An experimentalstudy of the effect of oral administration of blood on the stools. J Pediatr 1955;47:1-5. 2. Gotoff SP:The fetus and neonatal infant: Digestive system, in Beh~manR {ed): Nelson textbook of pediatrics, ed 14. Philadelphia: WB Saundors,1992:487. 3. Halliday HL, McClure G, Reid M: Handbookof Neonatallntensive Care. London:Bailliere Tindall, 1981:24, 209. 4. Apt L, DowneyJr WS: "Melena" neonatorum:The swallowed blood syndrome.J Pediatr 1955;47:6-12. 5. HodsonWA, TruogWE: Critical Care of the Newborn, ed 2. Philadelphia: Saunders,1989:96-£7. 6. ShermanNJ, ClatworthyJr HW: Gastrointestinalbleeding in neonates:A study of 94 cases. Surgery1957;62:614-519. 7. Harrison MR, deLerimierAA: Gastrointestinalhemorrhage,in PascoeDJ, GrossmanM (eds): Quick reference to pediatric emergencies, ed 3. Philadelphia: Lippincott, 1984:337-343. 8. GomellaTL (ed): Neonatolog~"Basic Management, On-CarlProblems, Disease, Drugs-1988-I989. Norwalk, Connecticut:Appleton & Lance, 1988. 9. KosloskeAM: Epidemiologyof necrotizing enterocolitis.Acta Podietr Supp11994;296:2-7. 10. Cotran RS, KumarV, Robbins SL: RobbinsPathologic Basis of Disease, ed 4. Philadelphia: WB Saundars, 198£:890. 11. Silber G: Lower gastrointestinal bleeding. PediatrRev 1990;12:85-93.
Reprint no. 47/1/72098 Address for reprints: Gail Rudnitsky,MD The Medical Collegeof Pennsylvaniaand HahnemannUniversity Department of EmergencyMedicine 3300 HenryAvenue Philadelphia,Pennsylvania19129
ANNALS OF EMERGENCY MEDICINE
27:5
MAY 1996