Crying and Irritability in the Young Child

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Chapter 10 Crying and Irritability in the Young Child

Robert G. Bolte, MD

1 Why is an organized approach important to the evaluation of crying in an infant?

The etiology of crying in the nonverbal and frequently uncooperative infant is often obscure. A well-organized approach is critical because the differential diagnosis is vast, ranging from a normal physiologic or temperamental response to life-threatening medical or surgical pathology. Finding the right answer with a reasonable utilization of resources is a big part of the “art” of pediatrics (Table 10-1).

Table 10-1 Relatively Frequent Serious Conditions Associated with Intractable Crying that must be Excluded Prior to Emergency Department Discharge

Condition	Clinical Correlates
Meningitis/encephalitis	Lethargy, vomiting, paradoxical irritability, fever
Sepsis	Lethargy, poor perfusion, fever, petechiae
Septic hip	Pain with range of motion/abnormal positioning of hip
Battered child syndrome	Bruising, bony tenderness, incompatible history
Shaken baby syndrome	Lethargy, full fontanelle, retinal hemorrhages
Intussusception	Paroxysmal abdominal pain, lethargy, bloody stool, abdominal mass; rectal examination may be abnormal
Volvulus	Bilious vomiting, abdominal tenderness
Appendicitis	Abnormal examination of abdomen
Incarcerated inguinal hernia	Abnormal examination of inguinal region
Hemolytic-uremic syndrome	Bloody diarrhea, hematuria/proteinuria, hemolytic anemia, thrombocytopenia, azotemia
Hypoxemia	Tachypnea, retractions, nasal flaring, wheezing, cyanosis
Hair encirclement	Abnormal examination of digits, genitalia, or uvula
Testicular torsion	Abnormal examination of scrotum
Supraventricular tachycardia	Heart rate >220 beats per minute

Bolte RG: Intractable crying in infancy and early childhood. In Aghababian RV (eds): Emergency Medicine: The Core Curriculum. Philadelphia, Lippincott-Raven, 1998, pp 622–630.

2 I work in an emergency department (ED) setting. Why do I have to know anything about colic?

It’s a commonly seen problem, even in an ED setting, representing a significant cause of parental anxiety and frustration.

If you know what colic is, then you’re less likely to misdiagnose more serious problems assuming that they are “only colic.”

3 Describe the clinical features of the infant colic syndrome.

Cyclic discrete periods of intractable crying, usually on a daily basis, with onset at 1–4 weeks of age and spontaneous improvement by 3–4 months of age. The classic definition of infantile colic was first described by Wessel in 1954 as “Crying lasting more than 3 hours per day, 3 days per week, and continuing more than 3 weeks in infants less than 3 months of age.” The crying is not relieved by normal parental interventions, such as feeding, burping, changing diapers, providing a pacifier, or rocking. Vomiting, diarrhea, or poor weight gain are not features of the infant colic syndrome.

Barr RG: Charging our understanding of infant colic. Arch Pediatr Adolesc Med 156:1172–1174, 2002.

Clifford TJ, Campbell MK, Speechley KN, Gorodzinsky F: Sequelae of infant colic: Evidence of transient infant distress and absence of lasting effects on matemal health. Arch Pediatr Adolesc Med 156:1183–1188, 2002.

4 Is there a “normal” amount of inconsolable crying in a young infant?

Brazelton’s data on how much time a normal infant spends crying inconsolably shows that the median daily amount of inconsolable crying at 2 weeks of age is 1 hour and 45 minutes. This increases to 2 hours and 45 minutes at 6 weeks of age and thankfully decreases to less than an hour by 12 weeks of age. Inconsolable crying usually occurs in the evening (between 3 PM and 11 PM) when most busy parents are frantically attempting to spend precious quality time with their new baby. Sharing this information with prospective parents may be the most effective argument for birth control that you can ever deliver.

Brazelton TB: Crying in infancy. Pediatrics 29:579–588, 1962.

5 Are there any effective treatments for colic?

There’s no magic remedy, but communicating empathy is crucial. Also, providing the family with accurate information on “normal” amounts of inconsolable crying and when they can expect improvement is always of value. A behavioral-modification approach described by Taubman has been shown to be helpful. Weizman and colleagues have reported that commercially available chamomile tea (not home-grown concoctions, which are potentially dangerous) may be useful. Simethicone (Mylicon; 0.3 mL given prior to each feeding) is basically a high-grade placebo, but at least it’s nontoxic. Generally avoid recommending formula changes (likely effective only in a subset of infants requiring hydrolysate formula) or medications with potentially toxic side effects, such as paregoric, dicyclomine (Bentyl), or hyoscyamine (Levsin).

Taubman B: Parental counseling compared with elimination of cow’s milk or soy milk protein for the treatment of infant colic syndrome: A randomized trial. Pediatrics 81:756–761, 1988.

Weizman Z, Alkrinawi S, Goldfarb D, et al: Efficacy of herbal tea preparation in infantile colic. J Pediatr 122:650–652, 1993.

6 What is the most common medical problem in young infants that mimics colic?

Esophagitis (secondary to gastroesophageal reflux). This is a ubiquitous condition in young infants, and presenting symptoms often mimic colic. With both conditions, infants present to the ED during the first few months of life with intractable crying as the chief complaint. In esophagitis, there is often a history of frequent nonforceful, nonbilious regurgitation following feedings. The infant with an irritated esophagus may take the first few sips of the feeding avidly, but then turns away, crying in pain. Occasionally the infant with esophagitis exhibits a torticollis-like positioning of the neck (Sandifer syndrome). Treatment can be initiated with medications such as antacids or ranitidine, with follow-up by the primary medical care provider.

7 A previously well 3-month-old presents with acute onset of intractable crying for the past 4 hours. The child is afebrile, and the general examination is normal. What is the most likely diagnosis?

Corneal abrasion. This etiology is relatively common but easily overlooked. In a prospective study by Poole, 21% of afebrile infants younger than 6 months of age presenting to an ED with a chief complaint of crying had corneal abrasions. But you’ll never diagnose it unless you first consider the possibility and then look for it by performing a corneal examination with fluorescein. Don’t be misled by the lack of eye redness or discharge; most infants with this diagnosis lack these findings. A hair tourniquet (Fig. 10-1) could also present like this, but a meticulous physical examination (of digits, penis, clitoris, and uvula) should make that diagnosis obvious. Non-accidental trauma (child abuse) must also be considered.

Figure 10-1 Hair tourniquet.

Poole SR: The infant with acute, unexplained, excessive crying. Pediatrics 88:450–455, 1991.

Rittichier KK, Roback MG, Bassett KE: Are signs and symptoms associated with persistent corneal abrasions in children? Arch Pediatr Adolesc Med 154:370–374, 2000.

Sytwestrzak MS, Fischer BF, Fischer H: Recurrent clitoral tourniquet syndrome, Pediatrics 105:866, 2000.

8 A nontoxic-appearing 5-week-old presents with fever and crying. The mother mentions that the crying increases during diaper changes. The cerebral spinal fluid and urinalysis results appear normal, a blood culture is pending, and you’ve initiated parenteral antibiotics. What else should be considered?

A septic hip. The evaluation and “processing” of the febrile child younger than 8 weeks of age can become so rote that we sometimes forget to perform a thorough physical examination, including the hips. A septic hip can occur in this age range and is a surgical emergency with devastating consequences if not recognized in time. The infant may exhibit “pseudo-paralysis” of the limb, with a preference for abduction and external rotation of the hip. Crying may increase at diaper changes as the parent inadvertently manipulates the hips. The peripheral white blood count is often normal. C-reactive protein and sedimentation rate are consistently elevated.

9 An 8-month-old white female presents with crying and a history of fever. In the ED, she is febrile but nontoxic in appearance, and the general physical examination is normal. What is the most likely “treatable” diagnosis?

Far and away, it is urinary tract infection (UTI), unless you consider viral illness “treatable.” In a 1998 ED study by Shaw et al, 16% of febrile white females younger than 2 years of age had a UTI—even if “otitis media, viral gastroenteritis, or upper respiratory infection” had been diagnosed. In the same cohort, if isolated fever was the only presenting symptom, an impressive 31% had a UTI. The rate of UTI in young Hispanic girls is probably comparable to that in whites; however, it is much lower than the rate in young African-American females.

Gorelick M, McGowan KL, Yakscoe NM, Schwartz JS: Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics 102:e16, 1998.

10 Are there any cardiac etiologies that present with crying as a chief complaint?

Somewhat surprisingly, supraventricular tachycardia was the ultimate diagnosis in 4% of the afebrile infants who presented with “excessive crying” in Poole’s 1991 ED study. Keep this pearl tucked away: If there is a history suggestive of paroxysmal tachycardia, remember that in the asymptomatic period, a delta wave (widened QRS with a slurred upstroke seen on 12-lead electrocardiogram) can give you the diagnosis.

Poole SR: The infant with acute, unexplained, excessive crying. Pediatrics 88:450–455, 1991.

Key Points: ED Evaluation of the Crying Infant

1 An organized approach is vital to appropriate diagnosis in the ED.

2 Routine use of “screening” laboratory studies and radiographs is generally not helpful.

3 A thoughtful history and a thorough physical examination are the cornerstones of diagnosis.

4 Knowledge of the natural history of colic can be an extremely useful tool in generating a differential diagnosis.

5 Awareness of potential life-threatening etiologies with crying as a presenting symptom (e.g., meningitis, shaken baby syndrome, intussusception) is paramount.

11 Name three relatively common, life-threatening surgical emergencies of infancy that you would expect to present with crying but in which crying sometimes is absent.

Intussusception: Generally presents with paroxysmal irritability, vomiting, and later bloody stool. But a significant subset of patients present with isolated lethargy. This usually afebrile infant may be misdiagnosed as having sepsis, a toxic ingestion, or a closed head injury. Intussusception generally presents in the 2-month to 2-year age range, with a peak at 9 months of age. In the lethargic infant, always palpate for abdominal masses, and if the diagnosis is in question, include a rectal examination. You may be surprised to find blood on the examining finger.

Midgut volvulus: Although crying may be associated with this diagnosis, most infants presenting with midgut volvulus are surprisingly nontoxic and calm in appearance, with a benign abdominal examination until the gut begins to infarct. Eighty percent of patients present in the first 4 weeks of life, and the cardinal diagnostic sign is bilious vomiting. If this diagnosis is suspected, an emergent upper gastrointestinal study is mandatory.

Shaken baby syndrome: Although this syndrome may present with crying and irritability, many infants have a chief complaint of listlessness or lethargy. In children under 2 years of age, your threshold for computed tomography of the head should be low. Although most infants with shaken baby syndrome do not have external signs of trauma, any facial bruising or intraoral trauma should be a major red flag. Retinal hemorrhage is generally the only physical finding (but unless the child is severely obtunded, it is problematic to diagnose). In a 1999 study by Jenny et al., physicians were most likely to miss this diagnosis if the family was white and both parents lived at home. In this same study, the most frequent misdiagnoses were viral gastroenteritis (persistent vomiting), accidental head trauma, rule-out sepsis, and colic.

Jenny C, Hymel KP, Ritzen A, et al: Analysis of missed cases of abusive head trauma. JAMA 281:621–626, 1999.

Reijneveld SA, van der Wal MF, Brugman E, et al; Infant crying and abuse. Lancet 364:1340–1342, 2004.

12 Are screening laboratory and radiologic tests generally useful in the ED evaluation of the young crying child?

The short answer is “no.” Routinely obtaining a panel of laboratory studies or x-rays as a diagnostic screen seldom adds to the evaluation (except for the expense). Generally the diagnosis lies in a thoughtful history and a thorough physical examination. In selected cases, specific laboratory tests or selected studies can certainly be of value (most commonly a catheterized urine specimen or a corneal examination with fluorescein). Sometimes the studies have critical importance (lumbar puncture in the child with meningitis, computed tomography of the head in shaken baby syndrome, air enema with intussusception, toxicology screen in methamphetamine exposure).

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