RHC for Health Professionals
- Concerns about the condition of a child (raised PEWS score): tachycardia, clinically dehydrated, fever
- Weight loss (acute or chronic)
- Acute onset of pain or irritability
- Large blood loss, or red currant jelly stool
- Melena
- Acute bloody diarrhoea
- Bilious, persistent, or large vomits associated with the PR bleeding
- Abdominal mass that does not feel like impacted faeces
- Bleeding from other areas (e.g. nose, mouth), bruising or petechiae
- Any child protection concerns
PR Bleeding: Advice for Referrers
Warning
The causes of PR bleeding vary with age. It can be fresh red blood (generally indicating bleeding from the lower GI tract) or melena (generally indicating bleeding from higher up in the GI tract). In relatively well children (i.e. those not thought to need acute referral to the hospital) consider the following:
- For infants the main causes to consider are cow’s milk protein allergy and constipation with a small tear. For a breastfeeding infant consider maternal cracked nipples.
- For older children consider constipation with an anal fissure, infectious enterocolitis, polyps, and inflammatory bowel disease.
It is important to refer acutely if there are any red flag features or concerns regarding acute illness.
Conditions to be concerned about include:
In infants/young children: necrotising enterocolitis, intussusception, volvulus, Meckel’s diverticulum
In older children: inflammatory bowel disease
Any age: infective diarrhoea
- Does the child have constipation or diarrhoea? Include length of altered stool pattern
- Stool frequency and type (use the Bristol Stool Chart if possible)
- Is the blood mixed in with stool, coating the stool, or present on wiping?
- Is it fresh blood or melena?
- Any associated symptoms: including abdominal pain or vomiting
- Growth of the child: are they gaining weight and length/height? Any evidence of faltering growth?
- Include birth weight if infant
- Fluid intake and information about diet, any recent changes?
- If they are breastfed does the mother have cracked nipples?
- If they are mixed feeding or formula fed – include which formula, volumes, any symptoms of cows milk protein allergy (either IgE-mediated or non-IgE mediated)? See Allergy Referral Guideline
- Medication history: any medications that cause change in colour of stool e.g. iron causing black stools
- Family history: any inflammatory bowel disease, polyposis, or coagulopathy
- Social history: travel history, any contact with animals, farms or another person with diarrhoea
- Any child protection concerns?
- General examination - any pallor, rashes, oral ulcers
- Abdominal examination - pain on palpation, any masses
- If anal inspection undertaken - any fissures or haemorrhoids?
- Include height and weight measurements
- If features of constipation - see constipation guidelines
- If features of non-IgE mediated cow’s milk protein intolerance - see allergy guidelines
- Bloody diarrhoea should be referred acutely – see HUS guideline
- Anal fissure evident – ensure passing soft stool, discuss hygiene, and refer to constipation guidelines
If the child is constipated:
- Signpost parents to the ERIC website, and encourage them to read the information and watch the videos
- Sign post parents to the Bowel and Bladder UK website: https://www.bbuk.org.uk/
- Ask parents to look at the ‘Bristol Stool Chart’ images available on the internet, and to assess and record the types of stool their child is passing each day
If the mother is breastfeeding and has cracked nipples refer to Infant Feeding Advisors. See Referral Form and information for parents on Breastfeeding Information for Primary Health Care Providers. Families can access resources using the following QR code:
