Chapter 7: Crying Infant

• The infant cry may signal hunger, an unmet need for attention, a diaper change, or distress or pain.

• An infant not interacting with the parents appropriately or with a high pitched cry should be considered as having a serious medical condition until proven otherwise.

• It is important to observe the infant for at least 1 to 2 hours if one has not identified the cause. If after this period of observation, the crying abates, the infant may be sent home after close follow-up is established with the primary care physician. If the crying persists, the clinician should proceed with a more complete workup.

• Common pitfalls in assessing the crying infant include not undressing the infant, not examining the oropharynx, failing to consider abuse, and failing to establish close follow-up.

The assessment of the acutely crying infant in the emergency department (ED) is challenging and the clinician must resist the urge to rush through the history and physical examination. Instead, the clinician must be deliberate in the search for the cause, since the clues to the diagnosis may be subtle. The clinician should perform serial observations and examinations until the cause is found or the infant returns to normal behavior. Fortunately, with a thorough history, a meticulous physical examination, limited diagnostic tests, and a period of observation in the ED, most of the diagnoses of the crying, irritable infant are identified.¹

To unravel the cause of acute, unexplained crying, it is important to know what normal infant crying encompasses and the definition of colic. Crying is part of normal psychomotor and psychosocial development and is the infant's source of communication. The infant cry may signal hunger, an unmet need for attention, a diaper change, or distress or pain.

The normal crying pattern in the first year of life has been described.² There is a progressive increase in crying, which peaks in the second month of life and then gradually decreases.^2,3 The peak crying time may be as much as 2 to 3 hours per day at 6 weeks of life.⁴ The daily crying time decreases when the infant has other ways to communicate, such as interacting with a social smile. Infant crying time has been reported to usually decrease to 1 hour a day by 14 weeks of age (3.5 months).³

Colic is a chronic crying syndrome that occurs in the first 3 months of life. The etiology of colic is unknown. Colic typically begins at 3 weeks of age in an otherwise healthy infant. The infant with colic cries more than 3 hours per day, more than 3 days per week, and at least 3 weeks in duration (the rule of 3s).⁵ During a colic episode, infants flex their legs, their faces turn red, and they expel flatus. These episodes usually take place in the early evening hours.⁵ Colic usually resolves by 3 to 4 months of age. Colic is a diagnosis of exclusion arrived at after careful history, physical examination, and workup as outlined below. It should be kept in mind that persistent crying in an infant is a risk factor for child abuse.

The cornerstone of colic treatment is reassuring the parents that this is a common, benign self-limited condition. Simethicone drops are widely used but there is little evidence to support their efficacy.⁶ There is little evidence to support any particular treatment of colic.⁶ Dietary changes (protein hydrolysate formula, soy formula, and maternal hypoallergenic diet in breastfeeding mothers)⁷ have been recommended as well as swaddling, vibration, and massage.⁶ Phenobarbital, dicyclomine (Bentyl), and ethanol should not be used because of the potential for significant adverse effects. There is some evidence to support the use of sucrose.⁸

Crying may also be a symptom of an underlying medical problem. The parents usually bring the infant to the ED because of the intensity and/or the duration of the crying and concern that their infant may be in pain. The clinician must differentiate between the benign and serious causes of crying. It is critical not to miss the serious causes because these may lead to untoward morbidity or death. In the seriously ill-appearing infant the assessment will occur in the critical care area of the ED with the history, physical examination, and diagnostic interventions occurring concurrently. This chapter focuses upon the well-appearing crying infant. Although the differential diagnosis is broad, an organized conservative approach with a thorough history and examination will narrow the differential in the majority of cases.¹

As Sir William Osler reminds us, “Listen to the patient, he is telling you the diagnosis.”⁹

Listen attentively to the history from the parents, since the clues to the diagnosis often lie in the history.¹ What elements should the history include? Crying should be investigated as a symptom. Questions should be directed to diagnose the symptoms: When did it start? What time of day? How long? What seems to provoke the crying? Was there any trauma? What alleviates the crying? What is the quality of the cry, high-pitched or weak? Are there any related symptoms such as fever, vomiting, diarrhea, constipation, cough, and nasal congestion? Has there been any exposure to illness? What is the duration of the crying? Is there a recurrent pattern?

Past medical history should include (i) perinatal and birth history: Is there any maternal history of herpes or recent cytomegalovirus (CMV) infection or of premature rupture of membranes? What is the mother's group B strep colonization status? Is there any history of maternal medication or drug abuse? If the infant is breastfeeding, maternal medication or drug intake is important as is caffeine consumption. Were there any neonatal problems? (ii) Immunization history: Has the infant had any immunizations? (iii) Growth and development: Has there been normal weight gain? Has the infant reached the appropriate developmental milestones? (see Chapter 1.)

If the crying is only with feeding, consider oropharyngeal pathology such as gingivostomatitis, herpangina, or even an oral burn. If the crying is only with a bowel movement, consider an anal fissure. Consider gastroesophageal reflux or esophagitis in the crying infant who arches the neck and back during or after feeding. Crying infants with milk allergy may present with vomiting or stools with blood or mucous. If there is any blood in the stool, also consider infectious enteritis.

Ask about the activity of the infant. How has the infant been acting other than this crying episode? Has there been any fever? Has the infant interacted normally with the parents prior to this episode of crying? What is the infant's intake and output? Questions related to the infant's intake refer to the feeding history, medication history, and possible toxin ingestion. Questions related to the infant's output include vomiting, diarrhea, constipation, hematochezia, or change in urination.

“The whole art of medicine is in observation … but to educate the eye to see, the ear to hear and the finger to feel takes time, and to make a beginning, to start a man on the right path, is all that we can do.”¹⁰

Vital Signs

Temperature: Temperature instability, fever, or hypothermia may represent sepsis. Check the pulse. Tachycardia may signal sepsis, dehydration, anemia, supraventricular tachycardia, or toxic ingestion. Bradycardia may signal sepsis, hypoxia, or ingestion. When observing respirations, note the rate, quality, and look for intercostals retractions. Capillary refill is used to assess hydration and perfusion status. Pulse oximetry may identify hypoxia and is useful if there are signs of any respiratory distress. Weight is an important “vital sign” in an infant. Normal weight gain is usually the sign of a healthy infant. Any acute illness in infancy, especially during the neonatal period, the first month of life, is likely to cause the infant to stop gaining weight.

Observation

The clinician should observe the infant with attention to the infant's color, quality of respirations (specifically noting any retractions), the infant's attentiveness, and the infant–parent interaction. An infant not interacting with the parents appropriately has a serious reason for crying. If the infant has paradoxical irritability (the crying increases rather decreases when picked up), consider meningeal or peritoneal irritation or fractures. Note the pitch of the cry, as this is important and will help the clinician decide the direction of the assessment. An infant with a high-pitched cry should be considered ill until proven otherwise. If the infant is ill-appearing, the history, physical examination, and resuscitation will be occurring simultaneously (Fig. 7-1).

Physical Examination

Initially, most of the physical examination of an infant can be done by observation with the infant in the parent's arms. The clinician should leave invasive examinations until last (fundoscopy, otoscopy, oropharynx examination, genital examination, and rectal examination). Completely undress the infant including the diaper. Lay the infant on its back on the examination table to assess movement of the extremities (asymmetry of movement may be the clue to a fracture) and for an adequate abdominal and genital examination. Inspect the genital area: look for symmetric testicles (testicular torsions) and abnormal masses (hernias) (Fig. 7-2).

Inspect the infant's complete skin surface. Hair tourniquets (Fig. 7-3) hide under clothing as can signs of child abuse (unusual bruising pattern). In a retrospective review of infants who presented to the ED with excessive, prolonged crying without fever and without a cause that was apparent to the parents, the physical examination revealed the diagnosis in 41% of the cases and provided clues to the final diagnosis in another 13%.¹ A complete physical examination should be performed with special focus upon the conditions known to cause persistent crying in infants (Table 7-1).

The differential diagnosis is broad (Table 7-1). If a detailed history and meticulous physical examination do not offer an explanation, two additional procedures and two laboratory screening tests should be considered. First, consider fluorescein staining of the corneas to rule out corneal abrasion. If this is the cause of the crying, application of topical ophthalmic anesthetic alone will stop the crying. The second procedure is a stool guaiac. In an infant, this is best obtained from stool sample on the rectal thermometer or a stool sample from the diaper. If positive, this may reflect milk protein allergy, anal fissure, or infectious enterocolitis. For screening tests, the urinalysis and urine culture should be obtained since occult urinary tract infections can occur.^1,11

If a diagnosis has still not been obtained, it is necessary to observe the infant in the ED for at least 1 to 2 hours. During this period of observation, redirecting the history as well as repeating the physical examination may be helpful in elucidating the diagnosis. If after this period of observation, the crying abates, the infant may be sent home with close follow-up established with the primary care physician. Contact the primary care physician who will be doing the follow-up. On the other hand, if after this period of observation, the crying persists in the well-appearing infant, the clinician should proceed with a more complete workup (consider obtaining a sepsis workup,¹² toxin screen, head CT scan,¹³ and skeletal survey¹⁴) and have the infant admitted for observation.

The author thanks Drs. Ingrid Henar, Grace Nejman, Thomas P. Martin, Madeline Simasek, and Ms. Elizabeth Meade.