Blood in your baby’s stool?! Get answers here!
Help! My baby has blood in her stool!
I don’t care what anyone says, but if you see blood in your baby’s stool it ALWAYS feels like an emergency.
I remember after Luke’s umbilical cord fell off there was a small amount of blood afterwards. Probably less blood than I shed writing this post (I am very clumsy, prone to paper cuts, and we have a new kitten currently climbing on my leg). But I remember it being far too much and needing to call Kristie to make sure it was ok (I’m a damned doctor but still defer the expertise of Doctor Mom).
So when your previously healthy baby starts having blood in their stool and diaper, it is understandable to be worried.
Usually, what happens is at an early age (2-8 weeks but can be later) you notice a bloody diaper/blood in stool, often with mucous, but that your child is “healthy otherwise.” Sometimes it happens later when you start change to formula or let your child start eating other foods (but over half the time it occurs while exclusively breast feeding)!
It is easy to recognize the symptoms and most people and most then see their provider. And that is the correct next step!
Note: if your infant has significant vomiting, diarrhea, dehydration and or lethargy then they may have FPIES. You should read this post after you take your child to the ER or provider’s office)
Before anything else, do this:
- First, if it is an emergency (continuous bleeding, lethargic or overly tired baby, decreased responsiveness or any other worrisome symptom) – GO TO THE ER IMMEDIATELY!
- Second, if you came to this site because you were googling symptoms of blood in stool, I want you to know that:
- About 64% of infant rectal bleeding is from food protein proctitis/proctocolitis.
- You should still see your pediatrician to confirm the diagnosis / make sure is no other cause
- Third, if you came to this site AFTER seeing your primary care provider about blood in stools, then I have A LOT of great information for you.
Table of Contents
This is a long post! Don’t get overwhelmed! I also included this guide so you can jump to a specific topic if you desire, or you canand read it all later!
- What causes food protein proctitis/proctocolitis (protein intolerance?)
- Who needs to avoid the food?
- How do you diagnose Food protein proctitis/proctocolitis?
- My approach to food elimination
- What is the long term plan?
- Now it’s time for questions
What causes food protein proctitis/proctocolitis (protein intolerance)?
Food protein proctitis/proctocolitis (also known as food protein allergy, allergic or eosinophilic proctocolitis) is NOT actually an allergy.
Remember, an allergy is an IgE-mediated immune response and traditionally causes food anaphylaxis, food-dependent eczema, or other IgE-mediated reactions.
Food protein proctitis/proctocolitis (protein intolerance) IS AN IMMUNE RESPONSE but not an IgE mediated response. The immune system is triggered by a food protein and causes inflammation in the colon and the end of the gastrointestinal tract (which is what causes the bleeding).
The proteins that trigger food protein proctocolitis/proctitis are different in each infant, and up to 8% can have multiple proteins causing the symptoms.
Most common food triggers of Food Protein Proctitis/Proctocolitis:
The most common foods that cause food protein proctitis/proctocolitis (protein intolerance) are:
- Cow’s Milk (76%) – Cow’s milk really does seem out to get you, doesn’t it?
- Eggs (16%)
- Soy (8%)
- Corn (2%)
- Unknown/no identifiable cause (8%)
These are the most common causes. Again, up to 8% of infants can have multiple food causing the symptoms so always keep an open mind to the possible foods (if you are unsure, a food journal is the right next step).
Other possible food triggers of Food Protein Proctitis/Proctocolitis
Truly, any food can be a trigger and as a parent, the key to not missing any food is to keep a food journal (I describe how below). But some of the other foods I have personally seen cause food protein intolerance are:
- Tree nuts (almond milk, almond butter, or other nut butter spreads)
- Peanuts (peanut also seem out to get you, don’t they?)
- Seeds (sunflower or sesame particularly)
- Meats (less common, but I’ve seen a pork and chicken cause it)
- There are more! (If you think a food is causing a symptom, ask me and I can help)
Who needs to avoid the food?
This is one of the biggest questions I get: who in the family needs to avoid the suspected foods?
- Your child – Easy answer first, but don’t give your child the identified foods:
- While not life threatening like food allergy, you DO need to avoid the food in all forms.
- You will need to do strict label reading for a while to accomplish this
- Breastfeeding mom – If you are breastfeeding, then you ALSO need to avoid these foods. Remember that over half of food protein intolerance infants present in exclusively breast fed children.
- You should start by avoiding these foods in all forms.
- It is possible you can become less strict over time, but that is part of the long term plan.
- NOT close contacts – in a food allergy, close contacts need to avoid the food due to cross contamination and contact allergy. That is not the same in this case. So there is no worry about other family members eating the food then kissing/touching your baby.
- I AGREE that this isn’t fair!
- I also AGREE that you should make your family avoid the food anyway or impose some other form of justice on them!
- (Wait, that’s NOT what you were thinking? Then you’re a better person than I).
How do you diagnose food protein proctocolitis/proctitis (protein intolerance)?
For the most part, history and physical exam only!
Allergy testing is NOT indicated unless you have symptoms of a food allergy or possibly eczema. Celiac testing / gluten testing is not indicated unless you have symptoms of celiac disease and imaging / GI consult is usually not necessary unless there are other warning symptoms.
The history is usually enough, but then needs to be followed with a food elimination challenge. This can be considered your diagnostic test:
- If elimination of the food fixes the problem, you have food protein proctitis/proctocolitis
- If elimination helps but not completely, you may have multiple food triggers
- If elimination does nothing to help, look for a different diagnosis.
How do you find what foods to eliminate?
This is a somewhat complicated answer. The main idea is:
- First, eliminate the foods to get your child back to normal
- Then, monitor introduction of other foods
- Make a list of “non-ok foods”
- If any food causes symptoms, add it to the list
- Keep that list with you and give to friends/family/daycare
My approach to food elimination – breast fed infants
Since this is not a life threatening problem, I usually eliminate 1 food at a time and use that to find the triggers.
- First, you should just avoid dairy in all forms!
- It is the most common cause (76%) so usually just eliminate it first.
- You need to do strict label reading, including eliminating the 29 other “names” of milk protein (you can download the list and a card to keep in your wallet HERE).
- The bleeding should improve within about 3 days but may take 2 weeks to fully heal.
- If you notice that symptoms are improving, wait about 2 weeks to see if they are all the way gone.
- If so, then you only need to avoid milk.
- If the bloody stools improve but do not completely get better, I would have you
- Avoid egg for 2 weeks and see if that makes a difference
- If it doesn’t, then avoid soy for 2 weeks and see if that helps
- If it doesn’t, then try to avoid corn for another 2 weeks.
- If none of that helps, then I recommend you keep a food journal of what you eat
- Write down your meals for the day and also track your infant’s stools.
- Remember there is often a few day lag in your infant’s symptoms (let’s say 2-5 days)
- If you want, I created a sample food journal you can download and use here
- Then, try and eliminate groups of food and see if they make a difference. If you are unsure, you can email me a copy of your food journal and I can help you make a plan.
- If you were ok changing to formula, you could consider changing to an extensively hydrolysis formula (read about this below).
- If none of this helps, then I would strongly recommend you take your infant to see a GI specialist to make sure nothing is being missed.
My approach to food elimination – formula fed infants
In many ways, a formula fed infant is a lot easier to manage regarding food elimination because you control the entirety of their nutrition. My recommendations are:
- First, switch to an extensively hydrolyzed formula (you can download a list here).
- We want to avoid milk-based formula because it’s the most common cause.
- We often recommend avoiding soy-based formula because it can also cause symptoms.
- As listed above, symptoms should get better within about 3 days and fully improve within 2 weeks.
- If symptoms get better, then you have one of two options:
- Continue with the extensively hydrolyzed formula
- You can consider trial of soy, monitoring to see if it causes any symptoms. I would only recommend this is cost or available of the extensively hydrolyzed formulas were an issue.
- If symptoms did not get better, then change to an amino acid based formula
- If symptoms get better you will need to stay on this formula
- If they don’t get better, then I recommend taking your infant to see a GI specialist
What is the long term plan?
Now for some good news: in general, food protein proctocolitis/proctitis usually goes away on it’s own and does so in the vast majority of infants (as opposed to true food allergy, which can be lifelong!)
As a general guidance:
- 50% of infants will outgrow food protein intolerance by 6 months
- 95% of infants will outgrow food protein intolerance by 9 months
Most providers are taught to wait a year before introducing foods. This approach is conservative and usually winds up forcing you to avoid food for longer than needed (if breast feeding) or possibly paying for expensive formula for longer than is necessary.
As a result, I often reintroduce foods between 6 or, ideally, 9 months of age.
There is a specific way to best introduce foods, and is a little beyond the scope of this blog because each infant is different in their food causes and background. However, because I know that this is done poorly by so many people, I have created a form that you can fill out and I can try to help you do it the right way.
Now it’s time for questions
This is, definitely, an epic blog post. I could probably do an hour long webinar just on this topic alone (if anyone is interested in that, please let me know)! But I did want to give you the correct information and help you as much as possible.
If I didn’t answer your specific questions, please just ask me and I’ll get you an answer (give me a day or so to write back, but I promise it’ll be a great answer).
Also, I recently wrote a food reaction central toolkit post to start to help everyone with food reactions (whether it is an adult, child or infant and ANY type of food reaction) and I’m also starting a “Food Reaction Facebook Group” where I can help but also where we can all help each other.
What can you do?
Food protein proctocolitis/proctitis is a big problem that often gets very poorly treated and leaves most parents with more questions than answers. So if you can, please SHARE this post as far as you can (Facebook or Pinterest, maybe) and let’s help other parents get the right answer.