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 (diagnosis of exclusion)
    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. Pneumonia
  4. Miscellaneous serious Causes
    1. Meningitis
    2. Testicular Torsion (especially if Undescended Testicle)
    3. Drug Ingestion
    4. Trauma
      1. Pediatric Fractures
      2. Subdural Hematoma
      3. Consider Child Abuse (Non-accidental Trauma)
      4. Compartment Syndrome (esp. Tibial shaft, Humerus, and Forearm Fractures)

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. Stranger anxiety does not start until age 8 to 9 months
    2. Stranger anxiety should not obviate a thorough evaluation for serious cause
  3. Consider parental factors
    1. Postpartum Depression
  4. Consider Nonaccidental Trauma
    1. Bruising in non-ambulatory infants <6 months (“If they don’t Cruise, they don’t Bruise”)

V. History

  1. History of present illness
    1. Sequential events that lead up to current presentation
    2. Crying patterns
      1. Crying onset, frequency, duration and time of day
      2. Provocative triggers
      3. Palliative measures (Interventions attempted)
    3. Prior similar episodes
  2. Habits
    1. Infant Feeding, intolerance or Emesis
    2. Voiding and Stooling
    3. Sleep patterns
  3. Birth History
    1. Gestational age
    2. Delivery complications
    3. Newborn Screen results
  4. Family History
    1. Congenital Disorders
    2. Metabolic Disorders
  5. Social History
    1. Recent Caregivers
    2. Number of children in home and age range
    3. Caregiver Support system
    4. Caregiver bond with child (observation if they are present)
    5. Risk for Toxin Ingestion
    6. Nonaccidental Trauma risks

VI. Exam

  1. Vital Signs
    1. Obtain full Vital Signs (Heart Rate, Blood Pressure, Respiratory Rate)
      1. Evaluate for Supraventricular Tachycardia
        1. Persistently high or very high Heart Rate (esp. >220 bpm)
    2. Obtain accurate Body Temperature (Rectal Temperature)
      1. Lower Temperature with antipyretics may console the child and will not mask serious illness
      2. Febrile child with significant illness (e.g. Sepsis, Meningitis) will remain ill appearing regardless of antipyretics
    3. Obtain a body weight and plot against an expected weight
      1. Identify Failure to Thrive
  2. General
    1. Observe child and their consolability with their Caregivers
    2. Undress the infant and perform a complete examination for organic cause
  3. HEENT Exam
    1. Scalp Hematoma (Closed Head Injury)
    2. Fontanelle
      1. Bulging Fontanelle may suggest Meningitis
      2. Sunken Fontanelle may suggest Dehydration
    3. Eyes
      1. Pupil Exam (Toxin Ingestion)
      2. Consider Retinal Exam (by ophthalmology if suspicious for Nonaccidental Trauma)
      3. Corneal Foreign Body (e.g. eye lash) or Corneal Abrasion
        1. Fluorescein Stain and Woods Lamp
        2. Corneal Abrasions are common (as many as half of asymptomatic infants)
        3. Continue to look for other causes of unconsolable crying even after Corneal Abrasion is found
        4. Consider Corneal Abrasion the cause of crying if Topical Anesthetic (tetracaine) relieves crying
        5. Shope (2010) Pediatrics (3):e565-9 [PubMed]
    4. Ears
      1. Otitis Media
      2. Ear Foreign Body
    5. Nose
      1. Obstruction (suctioning may clear, or may identify Nasal Foreign Body)
    6. Mouth
      1. Stomatitis
      2. Thrush
      3. Nonaccidental Trauma (frenulum tear)
  4. Cardiopulmonary Exam
    1. Lung Exam
      1. Respiratory distress (Tachypnea, intercostal retractions, accessory Muscle use)
      2. Rales
    2. Cardiovascular exam
      1. Perfusion and pulses
      2. Murmur
      3. Consider Congenital Heart Disease and Heart Failure
  5. Abdominal exam (for acute abdominal signs)
    1. Examine for abdominal mass or distention
      1. Examples: Intussusception, Bowel Obstruction, Midgut Volvulus, Pyloric Stenosis
    2. Examine for blood in the stool (e.g. Anal Fissure)
    3. Examine for Hernias
  6. Genitourinary exam
    1. Incarcerated Hernia
    2. Testicular Torsion
    3. Paraphimosis
    4. Penile Hair Tourniquet
  7. Neurologic Exam
  8. Musculoskeletal Exam
    1. Joint exam for Septic Arthritis, Osteomyelitis
    2. General exam for signs of Trauma or Fracture (consider Nonaccidental Trauma)
      1. Bruising
      2. Decreased extremity use
      3. Deformity (Fracture, dislocation)
  9. Skin Exam
    1. Evaluate for Hair Tourniquet (digits, penis)
    2. Evaluate for signs of Nonaccidental Trauma (Bruises, burns)

VII. 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 <4 months of age (10% have UTI)
    3. Overall, UTI represents 1% of causes of unconsolable crying

VIII. Imaging: Abdominal Ultrasound Indications

IX. 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

X. 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. Consider Abdominal Ultrasound (see above)
    2. Fluorescein stain the Cornea for Corneal Abrasion
    3. Stool Guaiac
    4. Urine Toxicology Screening
    5. Serum chemistry panel (including Serum Sodium, Serum Calcium)
    6. Consider Sepsis evaluation (ill appearing child)
    7. Consider head imaging (Nonaccidental Trauma)

XI. Management

  1. See Soothing the Crying Infant
  2. Manage reversible causes of inconsolability
  3. Consider observation for inconsolability of unknown cause in a less than well appearing child, or other red flags
  4. Discharge indications
    1. Well appearing infant
    2. Normal Vital Signs
    3. Normal feeding (observe before discharge)
    4. No red flag findings
    5. Consolable infant
    6. Reliable outpatient followup
    7. Reliable Caregivers, parents and social situation
      1. Observe interaction with Caregivers and their temperament before discharge
    8. Caregiver agrees with plan
  5. Discharge Instructions
    1. Reassurance regarding benign evaluation, but precautions regarding red flags for return
      1. Medical intervention for crying is required in <5% of cases
    2. Educate Caregivers on Nonaccidental Trauma
      1. Encourage Caregivers to take breaks, enlist a coping plan, maximize assistance and social support
      2. Shaking, smothering, striking or otherwise applying force can irreversibly injure or kill a child
      3. Shaken Baby Syndrome (Abusive Head Trauma of Infancy) affects up to 3000 infants in U.S. per year
    3. Infantile Colic is a diagnosis of exclusion
      1. However, if this is the cause of excessive crying, it resolves by 4 months of age
    4. Close follow-up (1 day) with a medical provider is needed for unidentified cause

XII. References

  1. Behar, Claudius and Painter in Herbert (2014) EM:Rap 14(12): 7-9
  2. Kosoko and Abraham (2021) Crit Dec Emerg Med 35(8): 3-9
  3. Freedman (2009) Pediatrics 123(3):841-8 [PubMed]
  4. Roberts (2004) Am Fam Physician 70:735-42 [PubMed]

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