I want to share my experience this weekend, regarding hemetest positive
stools in a baby on exclusive breastmilk, especially since this has been
an ongoing thread on LactNet lately.

Situation: A few weeks ago, a full-term mom came in to hospital in
active labor, fetal distress diagnosed on admission, went straight to
emergency cesarean (an impressive 9 minutes to delivery from time of
diagnosis of bradycardia!!), 4+ meconium below the vocal cords,
pneumothorax, received high-frequency ventilation with chest tubes,
required dopamine and phenobarb drips etc...bad meconium aspiration
syndrome. It is important to know that during this period, the baby
received Ranitidine with TPN to protect his gut during all this stress
(highly appropriate and the standard of care).

Now move forward to the present: at about 4 weeks old (45 weeks
gestational age) baby is in the grower-feeder room of the NICU trying to
learn how to feed. Unfortunately, he has significant neuro
disorganization and is struggling with learning to suck. OT/PT are
working with him in this breastfeeding-supportive hospital. He is
fortunate to have received no formula ever, only receiving EBM by either
gavage or nipple. He has had an occasional heme-positive stool, most
recently this past Friday, although his stools were heme negative over
the weekend. No-one knew where the blood was coming from, but since it
was infrequent, and he is gaining well, the docs were playing "wait and
watch."

Over the weekend, it was noted that he displayed a particular behavioral
pattern: eat, cry for 45-75 minutes (inconsolably unless over a shoulder
and being rocked), sleep. Because he had the same night nurse and day
nurse (myself) for 48 hours, and we were trying to figure out how much
of his crying was neuro (big possibility) vs colic (first guess by many:
blame mom's milk, as in, "it must be something she is eating") vs
wanting to be awake more (developmental issue),  we noticed a very
predictable pattern to the timing and quality of the crying. He started
crying almost exactly 30 minutes after feeding, each and every feeding.
The crying would last for about 1 hour. The only thing that comforted
him was to have his belly massaged (specifically the epigastric region)
or to have pressure against it (like a comfortable shoulder while being
held upright). Otherwise, he would tense his abdo and pull his legs up
and have a very distressed, wailing cry.

Yesterday, I came to wonder if this baby might have a duodenal stress
ulcer - not common, but not unusual either, given his history. In
general, pain *during* a meal can be indicative of a gastric ulcer,
while pain approximately 30-60 minutes after a meal can be indicative of
a duodenal ulcer (pain occurs as the meal empties from the stomach).

I was grateful the neonatologist did not laugh at my suggestion of an
ulcer, though he expressed (and I happened to agree actually) that the
chance was quite remote because he had received Ranitidine during his
NPO period. Nevertheless, the MD suggested I check for heme in the
gastric aspirate. On the next gavage feeding, since there was no
residual, I instilled some normal saline and removed it and used a
regular (urine) labstick to check for blood. It was positive for blood
at 10-50 erythrocytes/microLiter. The MDs were quite willing to
prescribe oral Ranitidine for him. Hopefully, his feedings will become
quite comfortable now, and maybe he'll be able to learn to suck, too, if
he's not distracted by pain.

Hmmm. As I write this, I'm wondering about his respiratory pattern
during feeding. What follows is pure speculation and should be taken as
such. His "normal" resp rate at rest runs about 80-100/minute, and
during a po feeding, he is tachypnic at a rate of 117-148 (with an
extremely disorganized suck when the resp rate exceeds 130 - no surprise
there.) (The surprise is that he could suck at all with a RR > 80-100!
Often, oral feeds are "held" for RR>80). Nonetheless, his oxygen
saturations are never less than 95%, and in fact are best (99-100%)
*during* nipple feeds. The assumption is he has meconium lungs. (His
heart rate is usually in 150s no matter his activity, which is very
ordinary for a term infant.) Yet I know from personal experience, when I
have had bad heartburn or gastritis, I sure don't breathe very deeply, I
guess because the movement of the lungs and diaphragm against the
stomach hurts too much. What if his tachypnea is actually a protective
"guarding" against pain? It could happen. The reason I make such a wild
suggestion, is because when I had time to sit and rock him upright over
my shoulder, it was the *only* time his vital signs were "normal":
HR=117-128 (lower!), RR= *38*  (!) (nice slow, deep & regular breaths),
O2 sat=100%. Mechanically, the position allows his stomach to be as far
below his lungs as possible and he can breathe normally. Maybe his lungs
are not as damaged as we think?

An interesting addendum, (great teaching visual aid for BF classes) in
case it is ever needed to demonstrate the presence of white blood cells
(leukocytes) in breastmilk, simply use a urine labstick in some EBM.
When I tested the gastric aspirate, the labstick was negative for
everything else *Except* it was wildly positive for leukocytes. I had
another nurse verify the heme findings with me, and she noticed the dark
purple patch for positive leukocytes and asked, "How come he's got white
cells in his stomach!?!"  For a moment, I, too, was at a loss, and then
the flash came - "Because he's on expressed breast milk and there are
white cells in the breast milk." "Oh...of course!"  Since the aspirate I
obtained was basically clear saline, this also (unofficially)
demonstrates that some white blood cells remain behind in the stomach
even after the feeding has "gone down."

Neat.    :-D

Katharine West, BSN, MPH
Sherman Oaks, CA