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In the population of healthy neonates, the incidence of upper gastrointestinal (GI) bleeding is uncommon but not rare. A case cohort series of 5180 infants indicated that approximately 1.2% of healthy infants experienced upper GI bleeding that was brought to medical attention.1 Incidence is likely increased in populations of more acutely sick neonates, such as those in the intensive care unit; however, the exact incidence is unknown, as some may have a high prevalence of asymptomatic gastritis.2 In the pediatric intensive care population, studies have shown that patients who receive acid-blocking prophylaxis have a lower incidence of upper GI bleeding,3 but a similar study was not found in the neonatal intensive care population.

The incidence of lower GI bleeding in the healthy neonatal population is unknown. One study in the tertiary emergency room setting had an incidence of 0.3% of all pediatric visits (n = 104), where the chief complaint was rectal bleeding. Of these, half of the patients were younger than 1 year old, and the most common diagnoses were allergic colitis and anorectal fissure.4 In the neonatal intensive care unit population, serious pathology such as neonatal necrotizing enterocolitis (NEC) and milk protein allergy has a higher prevalence than in the general population.4


The differential diagnosis, assessment, and treatment of GI bleeding in neonates, as in older children and adults, depend on identifying the location of the bleed. In neonates, it may be difficult to differentiate between upper tract and lower tract bleeding, as upper GI bleeding may be brisk and manifest as hematochezia due to the rapid intestinal transit time in infants.

The following are definitions used in this chapter:

  • Upper GI bleeding: bleeding arising proximal to the ligament of Treitz

  • Lower GI bleeding: bleeding distal to the ligament of Treitz

  • Hematemesis: Vomiting of blood, which may be obviously red or the color of coffee grounds (Table 38-1)

  • Hematochezia: Passage of fresh red blood per anus, usually in or with stools (Table 38-2)

  • Melena: Passage of dark, tarry stools

Table 38-1Neonatal Differential Diagnosis for Hematemesisa
Table 38-2Neonatal Differential Diagnosis for Hematocheziaa

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