Blood in nappy

Possible blood in nappy of infant

• Is it blood in the nappy ?
  • urinary urate crystals - can stain the nappy red - these are however not clinically significant (1)
  • medications
    • rifampicin products are excreted in the urine can make the stools appear red
      
      
• Points in the history
  • ? family history of a bleeding disorder
    
    
  • ? history of bleeding from other sites, such as the nose, or has any bruising
    
    
  • ? fresh or altered blood ? was blood mixed with the stools
    • bright red blood on a wipe or on a nappy (but not mixed with the stools) - this is suggestive of bleeding from the anal region
      • constipation and an anal fissure usually coexist in cases of blood in the nappy
        • constipation is the commonest cause of a rectal bleed beyond the neonatal period - this is irrespective of whether an anal fissure is visible or not (1)
    • blood mixed in with stool - this could be due to an intussusception
      • blood stained mucus that is characteristically passed is sometimes described as having a 'redcurrant jelly' consistency
      • may be an accompanying history of paroxysmal severe colic and episodic pallor
    • if the bloody stools are darker than normal or even black (assuming the baby is not being given iron supplements)
      • consider possible bleeding source higher up the gastrointestinal tract
        • possible causes include oesophagitis secondary to severe gastrointestinal reflux, Meckel's diverticulum, or a duplication cyst
          
          
  • ? was any associated pain
    • a fissure associated with constipation usually results in a baby straining and/or crying with pain during defecation
    • in contrast, rectal polyps present with more frequent painless bleeds
      
      
  • in breastfed infants, cracked nipples can lead to dark maternal blood in the baby's stool
    
    
  • enquire about characteristics of stools
    • if stools are more frequent and looser than usual, Campylobacter or Shigella infections, or other bacterial infection such as Clostridium difficile may be the cause. The latter may develop after the use of antibiotics. Bleeding is very rarely encountered in viral induced gastroenteritis
    • have other other family members been affected and enquire about recent travel
      
      
  • enquire about feeds
    • the type of feeds offered and whether there has recently been a change in the feeds
      • cows' milk allergy can cause blood in the stools; this is particularly common in formula fed infants with non-IgE mediated food allergy
        
      • there is often a family history of allergy and/or a personal history of eczema
        
        
• Examination
  • general examination
    • check for features such as bruising - may indicate a generalised bleeding disorder but also be aware of the possibility fo sexual abuse
    • is there clinical evidence of anaemia from a prolonged period of blood loss or dehydration from vomiting and/or diarrhoea
  • examine the abdomen
    • ? palpable stools or distension; the latter, depending on the clinical state of the child and presence of vomiting (often bile stained) may be due to malrotation with volvulus
    • an intussception may present with a sausage shaped lump in the right upper quadrant of the abdomen
    • inspection of anal area and nappy
      • anal area may reveal a fissure or macerated skin from a severe nappy rash
      • a rectal prolapse may be seen
        
        
• Investigation
  • stool sample for culture (bateria and viral) if suspected gastroenteritis
  • consider an allergy test
    • if suspected cow's milk allergy then a specific IgE against cows' milk protein can be requested
      • however there is no good diagnostic test for non-IgE mediated food allergy - therefore in appropriate cases consider a two to six week therapeutic trial of complete avoidance of cows' milk and products that contain milk
        
        
• Prescribe
  • prescribe stool softeners such as lactulose and an anaesthetic jelly for constipation or fissure
  • treat napkin dermatitis if cause of blood in napkin
    • if clinical differentiation of type of dermatitis (e.g. irritant napkin dermatitis, candidasis napkin dermatitis, seborrhoeic dermatitis) is not possible
      • then empirical therapy with a barrier cream (e.g. conotrane (R) or sudocrem (R)) plus
      • a combined topical steroid with antimicrobial preparation for 7 days e.g. timodine (R) cream (has antibiotic as well as antifungal properties) or daktacort (R) cream (hydrocortisone 1%, miconazole nitrate 2%

Referral for specialist review

• refer if there is frequent painless bleeding from a suspected rectal polyp
• refer if there is a single episode of blood in nappy if cause not likely to be 'obvious' such as napkin dermatitis, secondary to anal fissure, macerated skin secondary to gastroenteritis
• refer if repeated episodes of possible rectal bleeding
• refer urgently if rectal bleeding if there are clinical features of severe gastroenteritis or surgical conditions such as a Meckel's diverticulum, an intussusception, or rarely a duplication cyst (1)
• refer if possible bleeding disorder or cow's milk allergy

Be alert to the possibility of sexual abuse if there is vaginal bleeding or a very abnormal anus

• refer urgently if sexual or physical abuse is suspected

Reference:

• Gatrad AR, Sheikh A.Blood stained nappy.BMJ. 2012 May 24;344:e3496.