II. Epidemiology

  1. Organic cause is found in 5% of cases (with Urinary Tract Infection most common, especially <1 month old)

III. Differential Diagnosis

  1. Common Causes of an inconsolably Crying Infant
    1. Infantile Colic
    2. Corneal Abrasion or Eye Foreign Body
    3. Hair Tourniquet (hair strangulating appendage)
      1. Finger
      2. Toe
      3. Penis
  2. Gastrointestinal Causes
    1. Constipation
    2. Cow's Milk Protein Intolerance (peaks at 13 weeks)
    3. Pediatric Gastroesophageal Reflux
    4. Acute Gastroenteritis
    5. Lactose Intolerance
      1. Uncommon in young infants, but may present with Diarrhea and reducing substances in stool
    6. Anal Fissure
    7. Intussusception (especially over age 3 months)
    8. Intestinal Malrotation and Midgut Volvulus
    9. Incarcerated Hernia
  3. Infectious Causes
    1. Urinary Tract Infection
    2. Otitis Media
    3. Pharyngitis
    4. Pneumonitis
  4. Miscellaneous serious Causes
    1. Meningitis
    2. Trauma (e.g. Fracture, Subdural Hematoma): Consider Child Abuse (non-accidental Trauma)
    3. Testicular Torsion (especially if Undescended Testicle)
    4. Drug Ingestion

IV. Precautions

  1. Infantile Colic is a diagnosis of exclusion
    1. Normal physical exam
    2. Colic should follow rule of 3s
      1. Limited to age 3 weeks to 3 months (peaking at 6 weeks, and resolves by 4 months in 90% of cases)
      2. Three hours of crying for at least 3 days per week, occurring later in the day (after 3pm)
  2. Stranger anxiety is a diagnosis of exclusion
    1. Does not start until age 8 to 9 months
    2. Should not obviate a thorough evaluation for serious cause
  3. Consider parental factors
    1. Postpartum Depression

V. Exam

  1. Obtain Vital Signs (Heart Rate, Blood Pressure)
    1. Evaluate for Supraventricular Tachycardia
  2. Obtain a body weight and plot against an expected weight (identify Failure to Thrive)
  3. Undress the infant and perform a complete examination for organic cause
  4. Fontanelle (bulging Fontanelle may suggest Meningitis)
  5. Eyes for foreign body (e.g. eye lash) or Corneal Abrasion, and consider Retinal Exam
    1. Corneal Abrasions are common (as many as half of asymptomatic infants)
    2. Continue to look for other causes of Unconsolable Crying even after Corneal Abrasion is found
    3. Shope (2010) Pediatrics (3):e565-9 [PubMed]
  6. Ears for Otitis Media
  7. Nose for obstruction (suctioning may clear)
  8. Mouth for Stomatitis, Thrush or nonaccidental Trauma (frenulum tear)
  9. Lung Exam for respiratory disease
  10. Cardiovascular exam for perfusion and pulses (consider Heart Failure)
  11. Abdominal exam for acute abdominal signs
    1. Examine for abdominal mass (e.g. Intussusception)
    2. Examine for blood in the stool (e.g. Anal Fissure)
  12. Genitourinary exam
    1. Incarcerated Hernia
    2. Testicular Torsion
  13. Neurologic Exam
  14. Musculoskeletal Exam
    1. Joint exam for Septic Arthritis, Osteomyelitis
    2. General exam for signs of Trauma or Fracture (consider Child Abuse)
      1. Bruising
      2. Decreased extremity use
  15. Skin Exam
    1. Evaluate for Hair Tourniquet

VI. Labs

  1. No single battery of lab tests is recommended for Unconsolable Crying
    1. Testing should only be performed as indicated based on history and exam
    2. Lab abnormalities are identified in only 14% of Unconsolable Crying
  2. Catheterized Urinalysis
    1. Evaluate for Urinary Tract Infection when other etiology for Unconsolable Crying is not identified
    2. Obtain especially for excessive crying under 1 month of age (10% have UTI)

VII. Red Flags: Suggest organic cause

  1. Symptoms
    1. Apnea
    2. Cyanosis
    3. Shortness of Breath
    4. Persistent Unconsolable Crying during a 1-2 hour Emergency Department evaluation
  2. Signs
    1. Lethargy
    2. Tachypnea
    3. Decreased Capillary Refill
    4. Poor weight gain or weight loss
    5. Fever > 100.4 F

VIII. Evaluation: Second-line

  1. Indications
    1. Red-flag findings (e.g. persistent Unconsolable Crying in ED)
    2. Other suspicion for organic cause based on history and exam
  2. Testing
    1. Fluorescein stain the Cornea for Corneal Abrasion
    2. Stool Guaiac
    3. Urine Toxicology Screening
    4. Serum chemistry panel (including Serum Sodium, Serum Calcium)
    5. Consider Sepsis evaluation
    6. Consider head imaging

IX. References

  1. Behar, Claudius and Painter in Herbert (2014) EM:Rap 14(12): 7-9
  2. Freedman (2009) Pediatrics 123(3):841-8 [PubMed]
  3. Roberts (2004) Am Fam Physician 70:735-42 [PubMed]

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