Breastfed infant with sudden onset of “crayon orange” colored stools

February 15, 2011

Question:

I have a client who has a 20 day old newborn. Stools have been described as crayon orange for the last 24 hrs. Weight is 400 grams over birth. Blood tests indicate normal bilirubin levels. The exclusively breastfeeding baby is slightly yellow in color. No new medications since birth for mom or babe. Mom is finishing prenatal vitamins and iron supplement (which was initiated at 4.5 months of pregnancy). I have tried to find literature on same and have not found a good resource. Can you assist me in directing me to a good resource for this client to determine if this is of concern or not. Thanks.

Marni Hicks, Public Health Nurse, R.N., B.S.N.

Answer:

Barbara and Kay Respond

Your client is not alone! Many parents wonder about the appearance, frequency, and consistency of their baby’s bowel movements. Bright yellow stool are not uncommon in the breastfeeding infant (see photo). We searched PubMed for any citations specific to a “crayon orange” stool coloration, and did not find anything, so we will address your question a bit more generally.

Without seeing the stool, it is difficult to comment about a bright orange color. Changes in stool color are important to evaluate, because they may provide important diagnostic information with regard to serious medical conditions such as liver disease, bile duct blockages, and bleeding in the intestinal track.

stool of breastfeeding infant

An example of normal stool in an exclusively breastfeeding infant

Neonatal liver disease may be revealed by the signs and symptoms of jaundice and abnormal stool and urine color. Cholestatic liver disease is usually accompanied by pale stools and yellow or orange urine. “Pale” stool coloration is a lightening of the normal color, described as “clay-like.” If the urine of the baby in this case were crayon orange in color, perhaps it could be mistaken for orange, watery stool. However, blood tests revealed normal infant bilirubin levels. The mother’s medical care provider prudently investigated and failed to detect other symptoms of liver disease in the infant. (Crofts 1999)

Once bleeding and illness are ruled out, maternal dietary change may have caused temporary stool color changes. We have a photo in The Breastfeeding Atlas of bright green, “pesto poop” caused when a mom began using an herbal supplement. Common culprits that stain milk, and may discolor stools, are sports drinks, any food or beverages containing lots of food color (such as flavored gelatin), beets, carrots, greens, candy, herbal supplements, medications, teas. (Lawrence 2011)

Given the sudden change in this infant’s stool color, it would be productive to review what else changed in the few days previous. What did she ingest? Moms often do not connect eating lots of beets, for example, to producing pink stained milk, and red-tinged urine and stool. Use the list above to prompt mothers to make these associations. Unless women are pumping, they may not notice milk color changes.

You mention that the mom is not taking any new medications. She may not consider herbal tea or herbal supplements as medications. Is she taking or has she or the baby recently taken any antibiotics that might be interacting with her iron supplement? One article we reviewed referred to a “reddish color” change to the stool in an infant exposed to cefdinir (an extended-spectrum, third-generation cephalosporin antibiotic). When administered with iron-containing products, including infant formulas, “cefdinir or one of its metabolites may bind to ferric ions, forming a non-absorbable complex that imparts a reddish color to the stool.” The authors remarked: “With the recent approval of generic formulations of cefdinir, clinicians should be aware of this drug-drug interaction with iron-containing products to prevent unnecessary alarm by parents and caregivers, as well as costly medical evaluations for gastrointestinal bleeding.” (Lancaster 2008)

Because this mom consulted her baby’s medical care provider and ruled out illness, we agree that resources on normal infant stooling patterns may be helpful for her. You are welcome to share the link to our Diaper Diary products page, where your client may view some photos of infant stools.

Just a parting thought: Directly visualizing the stool color is important, but we know that a lot of our contacts are by phone or email. New technologies can assist in this kind of situation. Most people know how to take and send photos with cell phones. Next time instead of relying on a verbal description, consider asking your client to take a quick photo and forward it to you. You get more specific visual information and it is a great way to get started collecting photos for talks and teaching.

References:

Crofts DJ, Michel VJ, Rigby AS, et at. Assessment of stool colour in community management of prolonged jaundice in infancy. Acta Paediatr. 1999 Sep;88(9):969-74.

Lancaster J, Sylvia LM, Schainker E. Nonbloody, red stools from coadministration of cefdinir and iron-supplemented infant formulas. Pharmacotherapy. 2008 May;28(5):678-81.

Lawrence RA, Lawrence RM. Breastfeeding: A guide for the medical profession, 7th ed. Maryland Heights, MO: Elsevier Mosby, 2011. p. 314.

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