Differential Diagnosis of Upper GI Bleeding in Infants (<1 Year Old)
Age-Specific Etiologies
In infants less than 1 year old, mucosal bleeding from gastritis and stress ulcers represents the most common cause of upper GI bleeding, rather than the variceal or peptic ulcer disease seen in older children 1.
Primary Causes by Age Group
Neonates and Young Infants:
- Swallowed maternal blood (from delivery or breastfeeding) - must be excluded first as this is not true GI bleeding 2
- Stress gastritis/ulcers - particularly common in critically ill infants 1
- Gastritis - the predominant mucosal cause in this age group 1
- Vitamin K deficiency bleeding (hemorrhagic disease of the newborn) - especially in exclusively breastfed infants not given prophylaxis 1
Infants and Toddlers (up to 2 years):
- Mucosal bleeding (gastritis and stress ulcers) remains the leading cause 1
- Esophagitis - from gastroesophageal reflux disease 2, 3
- Mallory-Weiss tears - from forceful vomiting 3
- Coagulopathy - inherited or acquired bleeding disorders 2
Less Common but Important Causes
- Vascular malformations 3
- Duplication cysts 3
- Foreign body ingestion (particularly button batteries causing caustic injury) 3
- Milk protein allergy - can present with bloody emesis 3
Critical Initial Assessment Points
Determine if bleeding is truly from the upper GI tract by looking for:
- Hematemesis (vomiting blood - either bright red or coffee-ground appearance) 4, 3
- Melena (black, tarry stools indicating digested blood) 4, 3
- Exclude swallowed maternal blood using the Apt test in neonates 2
Assess severity immediately by evaluating:
- Hemodynamic stability - heart rate, blood pressure, capillary refill 2, 4
- Signs of shock - tachycardia, hypotension, altered mental status 1
- Volume of blood loss - ranges from minor streaking to life-threatening hemorrhage 3
Common Pitfalls
Most children with true upper GI bleeding require admission to a pediatric intensive care unit, so careful determination of whether reported blood represents actual GI bleeding is essential 2. In neonates, failure to perform the Apt test can lead to unnecessary invasive workup when the blood is maternal in origin 2.
Vitamin K deficiency is easily overlooked in exclusively breastfed infants who did not receive prophylaxis at birth, and empiric parenteral vitamin K (1-2 mg/dose in infants) should be administered in cases of major bleeding 1.