Hematemesis in the newborn period can be alarming for parents and doctors. In this edition of Briefs we are going to look specifically at bloody emesis only in the neonatal period – age less than 4 weeks. Obviously the initial questions should focus on the quantity and character of the vomiting. Was it spontaneous? After feeds? Streaks of red versus coffee grounds? Also, you’ll want to know if the infant is breast or bottle feeding as well as whether or not there is any history of familial milk protein intolerance or allergy. babies born at home might not have received Vitamin K, and thus are risk for hemorrhagic disease of the newborn.
Hematemesis, defined as the vomiting of blood, can range from fresh and bright red to old and dark (due to the effect of gastric acidity) with the appearance of “coffee grounds.” If the baby looks ill, then focus on the ABCs, IV access and resuscitation. Significant bleeding also merits the placement of an NG tube for a diagnostic saline lavage if the patient is stable enough. Again, this maneuver is not warranted for “streaks” of red blood, or just a singe episode. Lavage can help you confirm the rate and level. It does not halt or control hemorrhage – and a clear aspirate doesn’t rule it out either. 50ml of saline per lavage is appropriate for infants, whereas 100-200ml is for older children. Again, the rate of bleeding depends on what you see:
Red flecks or coffee grounds – LOW rate of bleeding
Bright red blood – FAST rate of bleeding
The rate is thought to be especially fast if the blood doesn’t clear with repeated lavage for 5-10 minutes. You really don’t need to perform lavage for greater than 10 minutes. Afterwards leave the tube to low wall suction to reduce the irritative effect of gastric blood.
Let’s move on to the differential diagnosis shall we? Again, especially in the well appearing newborn hematemesis is likely from swallowed maternal blood. In the first few days of life this could be from delivery – later on in the breast feeding infant. It is important to examine the mother’s nipples for cracked/bleeding skin. The best way to look for active nipple bleeding is to let the baby feed for a few minutes, then pull them away. If you see blood reassurance is all that is needed. You could have the lab perform the Apt test if available. This involves mixing the bloody sample sodium hydroxide. Fetal hemoglobin won’t denature and will remain pink. Adult hemoglobin will become brown. Of course, if the infant hasn’t vomited that much you won’t have a large enough sample.
Gastroesophageal reflux can result in hematemesis, but it is rare and generally seen only in babies that have more significant disease and/or vomit forcefully. Speaking of forceful vomiting, Mallory-Weiss tears can occur in babies too.
Another condition that can present with hematemesis is hypertrophic pyloric stenosis. Those that vomit blood are generally pretty ill appearing by the time they hit your ED. Babies in shock/sepsis can develop stress ulcers and ischemic breakdown of the stomach. I won’t belabor the point that GI hemorrhage can worsen shock and thus NG/OG tubes can be used for more than just air decompression of the stomach in the intubated baby. Critically ill children of any age are at risk for developing stress-related peptic ulcer disease. Such ulcers occur with life-threatening illnesses, including shock, respiratory failure, hypoglycemia, dehydration, burns (Curling’s ulcer), intracranial lesions or trauma (Cushing’s ulcer), renal failure, and vasculitis. These ulcers may develop within minutes to hours after the initial insult and primarily result from ischemia. Hematemesis, hematochezia, melena, and/ or perforation of a viscus may accompany stress-associated ulcers. Hematemesis secondary to gastroesophageal reflux and esophagitis is uncommon but should be considered in patients who are severely symptomatic with vomiting or aspiration. Hematemesis following the acute onset of vigorous vomiting or retching at any age suggests a Mallory-Weiss tear. These tears occur at the gastroesophageal junction due to a combination of mechanical factors (e.g., retching) and gastric acidity. Finally, the baby with perotinitis/acute abdomen could have necrotizing enterocolitis. This can occur in term newborns, but it’s pretty rare. It is more common in preemies.