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Melena in the newborn infant
M E L E N A 1N T H E N E W B O R N I N F A N T IRWN~ H. ROZ~NFEbD, M.D., AND JAMES R. MCGRATH, M.D. ~' CHICAGO,
H E quantity of blood necessary T for the f o r m a t i o n of a t a r r y stool in adults has been variously estimated at 50 to 100 e.c., ~, 2 but similar data for newborn infants have not previously been reported. Some older editions of pediatric texts a,* refer to bleeding f r o m a cracked nipple as a possible cause of melena in nursing infants, which would suggest that a relatively small amount of ingested blood would produce melena. The following case made us aware of the need f o r this information. CASE R E P O R T
J. M., Unit No. 470890. The i n f a n t was born a f t e r a full-term, uneompliBated pregnancy, and was delivered by outlet forceps following episiotomy. Respirations began spontaneously within one minute. The b i r t h weight was 3,300 grams. The initial physical examination disclosed no abnormalities and the baby was started on breast feedings. B y the fifth day, meconium had disappeared and the stools were yellow. H e regained his birth weight on the sixth day of life, and was circumcised on the eighth day. There was no evidence of an abnormal bleeding tendency at this time. On the tenth d a y of life, the baby passed two t a r r y stools. E x a m i n a t i o n showed a well-hydrated b a b y who was sleeping quietly and a p p e a r e d normal. The skin and mucous membranes showed no pallor, jaundice, petechiae, or eeehymoses. There was no evidence of bleeding in the mouth or nasopharynx. The lungs a n d heart were normal, and the abdomen was soft and F r o m t h e D e p a r t m e n t of P e d i a t r i c s , B o b s R o b e r t s :Yfemorial H o s p i t a l a n d t h e C h i c a g o Lying-in Hospital, University of Chicago. *Present address: Bellevue, Wash.
ILL.
nontender. The liver edge was felt 2 era. below the right costal margin, and the spleen and kidneys were not palpable. Hemoglobin was 17.2 grams per 100 ml. On the same day it was discovered that the m o t h e r ' s left nipple was cracked and bleeding. Breast feeding was discontinued t h a t afternoon. D u r i n g the night, there were two more t a r r y stools. On the following day, examination again showed a healthy looking i n f a n t in no distress and without evidence of disease. The hemoglobin was 15.0 grams per 100 m]., and the red blood count 5,300,000. The white blood count was 12,900; plate]ets 312,000; reticulocytes 1.2 per cent; hematocrit 45 p e r cent; differential, stab forms 13 per cent, segmented forms 42 per cent, lymphocytes 38 per cent, monocytes 6 per cent. The prothrombin time was 18 seconds (control 17 seconds). A stool passed later that day was yellow in color and showed one plus positive reaction for blood on benzidine test. The following day, the twelfth day of life, another yellow stool was only questionably, positive to benzidine. The hemoglobin remained at 15.0 grams. The b a b y w a s discharged with the diagnosis of "me!ena due to ingestion of blood ( m o t h e r ' s milk ?) . " NIETIfOD OF STUDY This study was u n d e r t a k e n to determine the amount of ingested blood oeeessary to cause t a r r y stools in the newborn infant. F r e s h blood was obtained b y femoral p u n c t u r e f r o m a baby, heparinized with powdered heparin and introduced into the same b a b y ' s stomach by means of a Levine tube. A record was then kept of the time, color, and consistency of each 180
ROZENFELD
AND
2r
GRATH:
]VIELENA
IN
NEWBORN
INFANT
]~]
I t has also been shown t h a t as long a n i n t e r v a l as seventeen h o u r s m a y e l a p s e b e t w e e n the i n g e s t i o n of blood a n d the p a s s a g e of a t a r r y stool.
stool f o r t h e n e x t t h i r t y - s i x hours. I n all eases, t h e i n f a n t s h a d y e l l o w stools w h i c h werd free of m e c o n i u m f o r a t least t w e n t y - f o u r hours, a n d none was b r e a s t f e d or r e c e i v i n g a n y i r o n p r e p aration. The p r o c e d u r e was c a r r i e d o u t w i t h twenty-four infants, ranging in weight f r o m 2,280 to 3,975 g r a m s . T h e r e s u l t s a r e shown in T a b l e I.
CONCLUSIONS 1. A s t u d y has been u n d e r t a k e n to d e t e r m i n e the a m o u n t of i n g e s t e d blood t h a t is n e c e s s a r y to p r o d u c e t a r r y stools in the n e w b o r n i n f a n t .
TABLE I AMOUNT NUMBER
0F
BABIES
TESTED
OF BLOOD (C.G)
8 1 7 8
GIVEN NUMBEI~
SI[0WING
2.0 2.6 3.0 5.0
MELENA
0 1 4 (i
TABLE I~ 9
WEIGHT (GRAMS)
TIME
C.C. OF BLOOD INGESTED
2,325 2,525 2,445 2,570 3,583 2,280 2,400 3,220 2,760 3,320 3,365
2.6 3.0 3.0 3.0 3.0 5.0 5.0 5.0 5.0 5.0 5.() DISCUSSION
Of t h e e i g h t who w e r e g i v e n 2 e.c. of blood, none h a d a t a r r y stool. One b a b y r e c e i v e d 2.6 e.c. of b l o o d a n d p a s s e d one t a r r y stool. F o u r of t h e seven g i v e n 3 e.e. of blood p r o d u c e d t a r r y stools, as d i d six of t h e e i g h t given 5 e.e. of blood. D a t a on those i n f a n t s who showed m e l e n a a r e g i v e n in T a b l e I I . These r e s u l t s i n d i c a t e t h a t as l i t t l e as 2.6 c.c. of blood, w h e n i n g e s t e d , m a y cause a t a r r y stool in t h e n e w b o r n inr a n t . H a d a l a r g e r n m n b e r of i n f a n t s been tested, it is possible t h a t a s m a l l e r a m o u n t of blood m a y h a v e been f o u n d to be o e e a s i o n a l l y sufficient.
OF
FIRST
APPEARANCE (HOURS)
NUMBER OF TARRy STOOLS
7 11 7 17 8 12 12 9 7 12 8
1 3 2 1 4 2 3 1 1 1 2
2. M e l e n a m a y be p r o d u c e d b y as l i t t l e as 2.6 c.e. of i n g e s t e d blood, a n d was p r o d u c e d i n f o u r of seven babies g i v e n 3 e.e. a n d in six of e i g h t babies g i v e n 5 e.c. of blood. 3. Of the g r o u p tested, those i n f a n t s who p a s s e d t a r r y stools d i d so f r o m seven to seventeen hours a f t e r the b l o o d was p l a c e d in t h e stomach. REFERENCES
1. Daniel, W. A., andEgan, B. S.: J . A . M . A. 113: 2232, 1939. 2. Schiff, L., Stevens, R. J., Shapiro, N , and Goodman, S.: Am. J. M. So. 203: 409, 1942. 3. Thursfeld and Paterson: Diseases of Children, Baltimore, 1928, Wm. Wood and Co., p. 90. 4. Abt, I.: Pediatries~ Philadelphia, 1924, W. B. Saunders Co., vol. IV.
H E quantity of blood necessary T for the f o r m a t i o n of a t a r r y stool in adults has been variously estimated at 50 to 100 e.c., ~, 2 but similar data for newborn infants have not previously been reported. Some older editions of pediatric texts a,* refer to bleeding f r o m a cracked nipple as a possible cause of melena in nursing infants, which would suggest that a relatively small amount of ingested blood would produce melena. The following case made us aware of the need f o r this information. CASE R E P O R T
J. M., Unit No. 470890. The i n f a n t was born a f t e r a full-term, uneompliBated pregnancy, and was delivered by outlet forceps following episiotomy. Respirations began spontaneously within one minute. The b i r t h weight was 3,300 grams. The initial physical examination disclosed no abnormalities and the baby was started on breast feedings. B y the fifth day, meconium had disappeared and the stools were yellow. H e regained his birth weight on the sixth day of life, and was circumcised on the eighth day. There was no evidence of an abnormal bleeding tendency at this time. On the tenth d a y of life, the baby passed two t a r r y stools. E x a m i n a t i o n showed a well-hydrated b a b y who was sleeping quietly and a p p e a r e d normal. The skin and mucous membranes showed no pallor, jaundice, petechiae, or eeehymoses. There was no evidence of bleeding in the mouth or nasopharynx. The lungs a n d heart were normal, and the abdomen was soft and F r o m t h e D e p a r t m e n t of P e d i a t r i c s , B o b s R o b e r t s :Yfemorial H o s p i t a l a n d t h e C h i c a g o Lying-in Hospital, University of Chicago. *Present address: Bellevue, Wash.
ILL.
nontender. The liver edge was felt 2 era. below the right costal margin, and the spleen and kidneys were not palpable. Hemoglobin was 17.2 grams per 100 ml. On the same day it was discovered that the m o t h e r ' s left nipple was cracked and bleeding. Breast feeding was discontinued t h a t afternoon. D u r i n g the night, there were two more t a r r y stools. On the following day, examination again showed a healthy looking i n f a n t in no distress and without evidence of disease. The hemoglobin was 15.0 grams per 100 m]., and the red blood count 5,300,000. The white blood count was 12,900; plate]ets 312,000; reticulocytes 1.2 per cent; hematocrit 45 p e r cent; differential, stab forms 13 per cent, segmented forms 42 per cent, lymphocytes 38 per cent, monocytes 6 per cent. The prothrombin time was 18 seconds (control 17 seconds). A stool passed later that day was yellow in color and showed one plus positive reaction for blood on benzidine test. The following day, the twelfth day of life, another yellow stool was only questionably, positive to benzidine. The hemoglobin remained at 15.0 grams. The b a b y w a s discharged with the diagnosis of "me!ena due to ingestion of blood ( m o t h e r ' s milk ?) . " NIETIfOD OF STUDY This study was u n d e r t a k e n to determine the amount of ingested blood oeeessary to cause t a r r y stools in the newborn infant. F r e s h blood was obtained b y femoral p u n c t u r e f r o m a baby, heparinized with powdered heparin and introduced into the same b a b y ' s stomach by means of a Levine tube. A record was then kept of the time, color, and consistency of each 180
ROZENFELD
AND
2r
GRATH:
]VIELENA
IN
NEWBORN
INFANT
]~]
I t has also been shown t h a t as long a n i n t e r v a l as seventeen h o u r s m a y e l a p s e b e t w e e n the i n g e s t i o n of blood a n d the p a s s a g e of a t a r r y stool.
stool f o r t h e n e x t t h i r t y - s i x hours. I n all eases, t h e i n f a n t s h a d y e l l o w stools w h i c h werd free of m e c o n i u m f o r a t least t w e n t y - f o u r hours, a n d none was b r e a s t f e d or r e c e i v i n g a n y i r o n p r e p aration. The p r o c e d u r e was c a r r i e d o u t w i t h twenty-four infants, ranging in weight f r o m 2,280 to 3,975 g r a m s . T h e r e s u l t s a r e shown in T a b l e I.
CONCLUSIONS 1. A s t u d y has been u n d e r t a k e n to d e t e r m i n e the a m o u n t of i n g e s t e d blood t h a t is n e c e s s a r y to p r o d u c e t a r r y stools in the n e w b o r n i n f a n t .
TABLE I AMOUNT NUMBER
0F
BABIES
TESTED
OF BLOOD (C.G)
8 1 7 8
GIVEN NUMBEI~
SI[0WING
2.0 2.6 3.0 5.0
MELENA
0 1 4 (i
TABLE I~ 9
WEIGHT (GRAMS)
TIME
C.C. OF BLOOD INGESTED
2,325 2,525 2,445 2,570 3,583 2,280 2,400 3,220 2,760 3,320 3,365
2.6 3.0 3.0 3.0 3.0 5.0 5.0 5.0 5.0 5.0 5.() DISCUSSION
Of t h e e i g h t who w e r e g i v e n 2 e.c. of blood, none h a d a t a r r y stool. One b a b y r e c e i v e d 2.6 e.c. of b l o o d a n d p a s s e d one t a r r y stool. F o u r of t h e seven g i v e n 3 e.e. of blood p r o d u c e d t a r r y stools, as d i d six of t h e e i g h t given 5 e.e. of blood. D a t a on those i n f a n t s who showed m e l e n a a r e g i v e n in T a b l e I I . These r e s u l t s i n d i c a t e t h a t as l i t t l e as 2.6 c.c. of blood, w h e n i n g e s t e d , m a y cause a t a r r y stool in t h e n e w b o r n inr a n t . H a d a l a r g e r n m n b e r of i n f a n t s been tested, it is possible t h a t a s m a l l e r a m o u n t of blood m a y h a v e been f o u n d to be o e e a s i o n a l l y sufficient.
OF
FIRST
APPEARANCE (HOURS)
NUMBER OF TARRy STOOLS
7 11 7 17 8 12 12 9 7 12 8
1 3 2 1 4 2 3 1 1 1 2
2. M e l e n a m a y be p r o d u c e d b y as l i t t l e as 2.6 c.e. of i n g e s t e d blood, a n d was p r o d u c e d i n f o u r of seven babies g i v e n 3 e.e. a n d in six of e i g h t babies g i v e n 5 e.c. of blood. 3. Of the g r o u p tested, those i n f a n t s who p a s s e d t a r r y stools d i d so f r o m seven to seventeen hours a f t e r the b l o o d was p l a c e d in t h e stomach. REFERENCES
1. Daniel, W. A., andEgan, B. S.: J . A . M . A. 113: 2232, 1939. 2. Schiff, L., Stevens, R. J., Shapiro, N , and Goodman, S.: Am. J. M. So. 203: 409, 1942. 3. Thursfeld and Paterson: Diseases of Children, Baltimore, 1928, Wm. Wood and Co., p. 90. 4. Abt, I.: Pediatries~ Philadelphia, 1924, W. B. Saunders Co., vol. IV.