Vaginal Bleeding in a 6-Day-Old Newborn Girl
This is physiologic withdrawal bleeding occurring in response to declining maternal estrogen levels after birth, and no intervention is required beyond reassurance. 1
Understanding the Physiology
Vaginal bleeding in the first week of life is a normal phenomenon affecting approximately 25% of newborn girls, with peak incidence on day 5 of life. 1 This bleeding results from:
- Withdrawal of maternal estrogens that the infant was exposed to in utero, causing endometrial shedding similar to menstruation 1
- Degenerative changes in the endometrium rather than true menstrual bleeding, often accompanied by diapedesis bleeding due to rapid hormone withdrawal 1
- Bleeding that is typically microscopic but can be macroscopically visible in approximately 3.3% of cases 1
When This is Normal vs. Abnormal
Normal physiologic bleeding:
- Occurs within the first week of life (your patient at day 6 fits this pattern) 1
- Light to moderate in volume 1
- Self-limited, resolving spontaneously 1
Abnormal bleeding requiring investigation:
- Bleeding that persists beyond one week of age 1
- Bleeding that appears for the first time after the first week of life 1
- Heavy bleeding that is disproportionate to expected physiologic withdrawal 2
Management Approach
For typical physiologic bleeding (as in this case):
- Provide parental reassurance that this is a normal finding 1
- No diagnostic workup is needed for bleeding occurring within the first week at this volume 1
- Observe for spontaneous resolution within days 1
Consider ultrasound evaluation if:
- Bleeding is unusually heavy or prolonged beyond one week, as this may indicate underlying Müllerian anomalies such as uterus didelphys (which presents with heavier bleeding due to larger endometrial surface area in two uterine cavities) 2
- The American Academy of Pediatrics recommends external examination only, assessing for signs of trauma, discharge, lesions, or masses if there is concern for pathology 3
Critical Pitfalls to Avoid
- Never perform digital vaginal examination in prepubertal children, as this is inappropriate and traumatic 3
- Do not assume pathology when bleeding occurs at day 5-7 of life, as this is the peak time for physiologic withdrawal bleeding 1
- Do not overlook congenital adrenal hyperplasia if bleeding occurs later (after 2-3 months) following glucocorticoid treatment initiation, as this can trigger transient gonadotropin elevation and menses 4
Follow-Up Recommendations
- Schedule follow-up only if bleeding persists beyond 7-10 days of life 1
- Instruct parents to return immediately if bleeding becomes heavy, is accompanied by abdominal distension, or if a palpable mass develops 3
- Routine transabdominal ultrasound should be considered if bleeding is abnormally heavy, as early diagnosis of Müllerian anomalies facilitates timely intervention and screening for associated conditions 2