Dr. Batul Kaj: A 14-month-old boy was evaluated in the pediatric gastroenterology clinic of this hospital because of vomiting. The patient was born at another hospital to a 35-year-old mother by cesarean section because of arrest of the second stage of labor after an uncomplicated gestation of 39 weeks 6 days. At delivery, meconium was present. The 1-minute and 5-minute Apgar scores were both 9, and the birth weight was 2.9 kg (23rd percentile) (Fig. 1). Breast-feeding was initiated. The results of newborn blood-spot screening tests (a panel of tests for multiple congenital diseases, primarily inborn errors of metabolism) and screening tests for hearing ability and critical congenital heart disease were normal, and the patient was discharged home on the fourth day of life. At a routine pediatric examination when the patient was 14 days of age, the patient's mother reported that she had been breast-feeding him for 20 minutes every 2 to 3 hours and that he was having yellow, seedy stools after each feeding. The weight was 2.7 kg. The patient's mother was advised to begin pumping breast milk and fortifying it with a cow's milk-based infant formula to achieve a caloric content of 0.74 kcal per milliliter. Eight days later, the weight was 2.8 kg, and fortification to 0.81 kcal per milliliter was recommended. At 26 days of age, the patient vomited a small amount of clotted blood, and his parents took him to the emergency department at another hospital. They reported that the baby had begun having frequent nonprojectile, nonbloody, nonbilious “spit ups” after the initiation of formula-fortified expressed breast milk. The physical examination was normal. A test of the stool was positive for occult blood. The patient was monitored overnight; he had no recurrent hematemesis and was discharged home the next day. At a follow-up visit with the pediatrician 9 days later, the weight was 2.8 kg, and the patient was referred to a pediatric gastroenterologist at this hospital.
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