What causes gastrointestinal (GI) bleeding in neonates?

Updated: Dec 19, 2018
  • Author: Wayne Wolfram, MD, MPH; Chief Editor: Robert K Minkes, MD, PhD  more...
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Anal fissures are the most common cause of GI bleeding in infants. Typically, bright red blood streaks the stool or causes spots of blood in the diaper. The cause is a tear at the mucocutaneous line, most commonly located dorsally in the midline.

Other common causes of apparent neonatal GI bleeds include bacterial enteritis, milk protein allergies, intussusception, swallowed maternal blood, and lymphonodular hyperplasia. Milk or soy enterocolitis, or allergic colitis, is a cause for vomiting with blood staining after the introduction of these food products into the diet.

Erosions of the esophageal, gastric, and duodenal mucosa are also a frequent cause for true neonatal GI bleeding. Presumably, this damage is caused by the dramatic increase in gastric acid secretion and the laxity of gastric sphincters in infants.

Maternal stress in the third trimester has been proposed to increase maternal gastrin secretion and enhance infantile peptic ulcer formation.

Neonatal peptic ulcer disease has not been associated with mode of feeding or hyperalimentation.

Some drugs are implicated in neonatal GI bleeds. These include NSAIDs, heparin, and tolazoline, which are used for persistent fetal circulation.

Indomethacin, used for patent ductus arteriosus in neonates, may cause GI bleeding through intestinal vasoconstriction and platelet dysfunction.

Maternal medications can cross the placenta and cause problems in the developing fetus and in the neonate on delivery. Aspirin, cephalothin, and phenobarbital are well-known causes of coagulation abnormalities in neonates.

Stress gastritis occurs in up to 20% of patients cared for in neonatal intensive care units (ICUs). Prematurity, neonatal distress, and mechanical ventilation are all associated with stress gastritis.

Stress ulcers in newborns are associated with dexamethasone, which can be used for fetal lung maturation.

Rarer causes of GI bleeding in a neonate include volvulus, coagulopathies, arteriovenous malformations, necrotizing enterocolitis (NEC; especially in preterm infants), Hirschsprung enterocolitis, and Meckel diverticulitis.

Hemorrhagic disease of the newborn is a self-limited bleeding disorder resulting from a deficiency in vitamin K–dependent coagulation factors. levels of clotting factors II, VII, IX, and X decline rapidly after birth, reaching their nadir at 48-72 hours of life. In 0.25%-0.5% of neonates, severe hemorrhage may result.

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