Introduction

Gastrointestinal (GI) bleeding in infants and children is an uncommon cause of presentations to an emergency department (ED) but nonetheless is an alarming symptom that concerns parents greatly. Fortunately, in the majority of infants and children, the cause is benign or relatively uncomplicated, and not associated with significant morbidity or mortality. There are, however, some less common conditions that occur in infancy and childhood that may be a cause of potentially life-threatening blood loss and require rapid assessment and resuscitation.

The epidemiology of GI bleeding in children is very limited. The reported incidence of GI bleeding of 6.4% in paediatric ICU patients¹ and the most frequent diagnoses confirmed endoscopically² (duodenal and gastric ulcers, oesophagitis, gastritis, and varices) represent selected populations and are not representative of the ambulatory paediatric population.

Aetiology

The aetiology of GI bleeding is best considered within defined age groups, with some overlap between groups, and the likely location of the bleed, as guided by history and examination (see Tables 7.2.1 and 7.2.2).

The term newborn infant who is breast fed and has GI bleeding is most likely to have ingested maternal blood either at the timeof delivery or from breast feeding from cracked nipples. Premature infants are at an increased risk of necrotising enterocolitis, although it can occur in term neonates with birth asphyxia or cyanotic heart disease. Any sick newborn, compromised by hypoxia or hypotension is at risk of GI bleeding from stress ulcers. An infant who has not received parenteral vitamin K after birth, or has interference with vitamin K absorption, is at risk of haemorrhagic disease of the newborn. Formula fed infants may develop cow’s milk protein intolerance within the first few weeks to months.

The bowel habit of the infant or child prior to onset of GI bleeding is important to note. Constipation associated with pain when straining at stool would make an anal fissure a probable diagnosis. The older infant or child with cerebral palsy may have severe gastro-oesophageal reflux and therefore most likely has an oesophagitis-related source of upper GI bleeding.

The key factor in identifying the cause of GI bleeding in toddlers and older children is the presence of associated symptoms. Crampy abdominal pain and diarrhoea with mucus and fresh blood may be caused by infectious gastroenteritis due to Campylobacter, Shigella, Salmonella and Yersinia. Intermittent colicky abdominal pain with episodes of lethargy occurring in intussusceptions may manifest with blood in the stools as a late sign. Henoch–Schönlein purpura will manifest with the typical palpable purpura on extremities as well as abdominal pain. Certain diagnoses also have a recognised age pattern; juvenile polyps have a peak incidence of 1 to 6 years of age, intussusception peaks at 5 to 18 months, and inflammatory bowel disease more commonly presents in adolescence, although can occur at any age.