The case

A one month old baby boy is growing and thriving – but has been directed to the ED at 11:15 PM on a Tuesday evening because of blood in his stools. The parents called the on call line for their primary care doctor and were directed to the Emergency Department. The patients was a full-term infant with no complications or issues for mom during pregnancy. he was born in a hospital and received vitamin K. He did not bleed excessively following his circumcision. He has been growing and thriving, and has no fevers, respiratory symptoms or fussiness. He is feeding with a milk based formula, 3 ounces every 3 hours and has been having 5-7 yellowish-brown soft seedy stools every day for the past few weeks. Over the past 3 to 4 days his stools have been looser – with no substantial change in frequency. Today the parents noted some streaks of bright red blood mixed with the stool on 3 separate diaper changes.

Physical exam reveals an alert baby boy, with normal tone, a soft benign abdomen, no anal fissures and no rashes or jaundice.

The diagnosis

This is almost certainly milk induced colitis (AKA milk-protein induced proctocolitis), which is an inflammatory reaction caused by the ingestion of milk proteins. It can also be caused by soy. Therefore, this can also be called food protein induced-proctocolitis. This is a problem almost exclusive to infants and generally resolves around 6 months to a year and a half of age. It is most common in babies that eat milk or soy based formula – and is more rarely seen from the milk products in a breastfeeding mom’s diet.

It is interesting to note that 25% of babies in the western hemisphere with reaction to milk also have symptoms with soy. Nevertheless, the treatment is as follows:
Reassurance that this is not something catastrophic like an infection or necrotizing enterocolitis and that this will generally resolve by 18-months of age, at which time a normal diet can be resumed
Discuss changing the formula with the parents and the Primary Care Doctor (remember this is an Emergency Medicine blog) to a casein-hydroxylate formula (Similac Total Comfort, Enfamil Gentelease, Gerber Gentle) or an amino-acid based formula (Alimentum)
If mom is breast feeding this will require elimination of cow’s milk protein from her diet

ED Pearls

In order to suspect this diagnosis the baby MUST be well appearing, and have no other cause for the bleeding on history of physical exam like anal fissure, rectal prolapse, or in the case of the ill appearing newborn NEC
It is challenging to suggest and arrange changing a formula in the ED – that is why you must discuss your diagnosis with the family and the child’s primary acre doctor
If you are unsure whether or not it is blood go ahead and get a stool guaiac. Remember that urate crystals in the diaper are orangish-pink but can be mistaken for bloody urine or stools.

Edit: In an earlier edition of the post I had an autocorrect related error – “crate crystals” instead of urate crystals. Thanks for the feedback James.This has now been fixed.