Pediatric emergency medicine trisk 0697 0697
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volvulus and signifies vascular compromise. NEC, most common in preterm infants
(although 10% occur in term infants), signifies sections of bowel tissue necrosis. The
diagnosis of Hirschsprung disease should be considered in any newborn who does not
pass meconium in the first 24 to 48 hours of life. Twenty-five percent of neonates with
Hirschsprung disease have enterocolitis that may present with GI bleeding. The risk of
enterocolitis remains high until about 6 months of age.
Infancy (1 Month to 2 Years)
In the first 2 years of life, anal fissures and colitis (including infectious and allergic) are
among the most common causes of rectal bleeding. Anal fissures are usually associated
with constipation or trauma (rarely, this trauma can be nonaccidental). Infectious
enterocolitis as a cause of bloody diarrhea is common in all age groups.
Pseudomembranous colitis should be considered in any infant or child with bloody
stools and a history of recent antibiotic therapy. “Nonspecific colitis” is a common cause
of hematochezia in infants younger than 6 months of age and may represent a variation
in the colonic response to viral invasion.
Milk- or soy-allergic enterocolitis causes bloody diarrhea and usually occurs during
the first month of life, but can occur in older children depending on food exposure.
Trialing a change in formula from cow’s milk or soy protein to an elemental formula
(Nutramigen, Alimentum, Pregestimil) can also help to assess for milk protein allergy.
Breast-fed infants whose mothers drink cow’s milk may develop an allergic colitis that
responds to removal of cow’s milk from the mother’s diet.
Food protein–induced enterocolitis syndrome (FPIES) represents a rare (affects up to
0.34% of infants) but severe, non–IgE-mediated food hypersensitivity that causes severe
vomiting and diarrhea (often bloody) within hours of offending food ingestion.
Symptoms, including hypovolemic shock, typically begin in the first month of life, with
a mean age at initial presentation of 5.5 months. Infants typically react to one or two
specific foods with the most common being soy and cow’s milk, and, less commonly,
rice, vegetables, fruits, meats, oats, egg, and fish. Most children develop tolerance to the
offending food trigger by 3 years of age.
Meckel diverticulum should be suspected in infants or young children who present
with intermittent painless rectal bleeding (dark or red blood) that may cause massive GI
hemorrhage. Sixty percent of complications from Meckel diverticulum (hemorrhage and
intestinal obstruction) occur in patients younger than 2 years of age. Idiopathic
intussusception may occur in infancy, with 80% occurring before 2 years of age.
Lymphonodular hyperplasia is an uncommon cause of rectal bleeding in this age group
and may cause mild, painless hematochezia that is self-limited. Intestinal duplications
are also an uncommon cause of lower GI bleeding and, when diagnosed, are usually
found in children younger than 2 years of age. Duplications can be found anywhere in
the GI tract but are most common in the distal ileum and usually present with
obstruction and lower GI bleeding.
