If the Apt test is not available, manage practically and safely.
In a 13-day-old with hematemesis, previous cracked nipples, and reflux-like symptoms — here’s what to do:
✅ Stepwise Approach Without Apt Test
1️⃣ Check if baby is clinically well
Feeding well?
Normal vitals?
No pallor?
No abdominal distension?
No ongoing bleeding?
If well-appearing with small streaks of blood, maternal source is most likely.
2️⃣ Examine the mother carefully
Inspect nipples for:
Cracks
Bleeding points
Scabs
Express breast milk (EBM):
Look for pink/red discoloration
Do dipstick for blood on EBM
Positive → likely swallowed maternal blood
3️⃣ Basic labs (if true neonatal bleed suspected)
If:
Persistent hematemesis
Moderate/large volume
Baby symptomatic
Order:
CBC
PT/INR, aPTT
Consider platelet count specifically
Think especially about:
Vitamin K deficiency bleeding (late VKDB) at 2 weeks
Gastritis/reflux esophagitis
🧠 Practical Clinical Clues
| Feature | Suggests Maternal Blood |
|---|---|
| Small streaks only | ✔ |
| Baby otherwise well | ✔ |
| Occurs after breastfeeding | ✔ |
| Cracked nipples present/recent | ✔ |
| Feature | Suggests Neonatal Source |
|---|---|
| Recurrent vomiting with blood | ✔ |
| Pallor | ✔ |
| Abnormal vitals | ✔ |
| No maternal nipple bleeding | ✔ |
🩺 If Baby Well and Maternal Source Likely
Continue breastfeeding
Optimize latch
Treat maternal nipple trauma
Observe
🚨 If Concern for True GI Bleed
Give Vitamin K (if status uncertain)
Start PPI if reflux suspected
Admit for monitoring if significant bleed
Exam Pearls:
In neonates, most common cause of hematemesis = swallowed maternal blood, especially in first 2 weeks.
If you want, I can give a quick viva-style answer format for this case.
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