II. Epidemiology
- Organic cause is found in 5% of cases (with Urinary Tract Infection most common, especially <1 month old)
III. Differential Diagnosis
- Common Causes of an inconsolably Crying Infant
- Infantile Colic
- Corneal Abrasion or Eye Foreign Body
- Hair Tourniquet (hair strangulating appendage)
- Finger
- Toe
- Penis
- Gastrointestinal Causes
- Constipation
- Cow's Milk Protein Intolerance (peaks at 13 weeks)
- Pediatric Gastroesophageal Reflux
- Acute Gastroenteritis
- Lactose Intolerance
- Uncommon in young infants, but may present with Diarrhea and reducing substances in stool
- Anal Fissure
- Intussusception (especially over age 3 months)
- Intestinal Malrotation and Midgut Volvulus
- Incarcerated Hernia
- Infectious Causes
- Miscellaneous serious Causes
- Meningitis
- Testicular Torsion (especially if Undescended Testicle)
- Drug Ingestion
- Trauma
- Pediatric Fractures
- Subdural Hematoma
- Consider Child Abuse (Non-accidental Trauma)
- Compartment Syndrome (esp. Tibial shaft, Humerus, and Forearm Fractures)
IV. Precautions
-
Infantile Colic is a diagnosis of exclusion
- Normal physical exam
- Colic should follow rule of 3s
- Limited to age 3 weeks to 3 months (peaking at 6 weeks, and resolves by 4 months in 90% of cases)
- Three hours of crying for at least 3 days per week, occurring later in the day (after 3pm)
- Stranger anxiety is a diagnosis of exclusion
- Does not start until age 8 to 9 months
- Should not obviate a thorough evaluation for serious cause
- Consider parental factors
V. Exam
- Obtain Vital Signs (Heart Rate, Blood Pressure)
- Evaluate for Supraventricular Tachycardia
- Obtain a body weight and plot against an expected weight (identify Failure to Thrive)
- Undress the infant and perform a complete examination for organic cause
- Fontanelle (bulging Fontanelle may suggest Meningitis)
- Eyes for foreign body (e.g. eye lash) or Corneal Abrasion, and consider Retinal Exam
- Corneal Abrasions are common (as many as half of asymptomatic infants)
- Continue to look for other causes of Unconsolable Crying even after Corneal Abrasion is found
- Shope (2010) Pediatrics (3):e565-9 [PubMed]
- Ears for Otitis Media
- Nose for obstruction (suctioning may clear)
- Mouth for Stomatitis, Thrush or Nonaccidental Trauma (frenulum tear)
- Lung Exam for respiratory disease
- Cardiovascular exam for perfusion and pulses (consider Heart Failure)
- Abdominal exam for acute abdominal signs
- Examine for abdominal mass (e.g. Intussusception)
- Examine for blood in the stool (e.g. Anal Fissure)
- Genitourinary exam
- Neurologic Exam
-
Musculoskeletal Exam
- Joint exam for Septic Arthritis, Osteomyelitis
-
General exam for signs of Trauma or Fracture (consider Child Abuse)
- Bruising
- Decreased extremity use
- Skin Exam
- Evaluate for Hair Tourniquet
VI. Labs
- No single battery of lab tests is recommended for Unconsolable Crying
- Testing should only be performed as indicated based on history and exam
- Lab abnormalities are identified in only 14% of Unconsolable Crying
- Catheterized Urinalysis
- Evaluate for Urinary Tract Infection when other etiology for Unconsolable Crying is not identified
- Obtain especially for excessive crying under 1 month of age (10% have UTI)
VII. Red Flags: Suggest organic cause
- Symptoms
- Apnea
- Cyanosis
- Shortness of Breath
- Persistent Unconsolable Crying during a 1-2 hour Emergency Department evaluation
- Signs
- Lethargy
- Tachypnea
- Decreased Capillary Refill
- Poor weight gain or weight loss
- Fever > 100.4 F
VIII. Evaluation: Second-line
- Indications
- Red-flag findings (e.g. persistent Unconsolable Crying in ED)
- Other suspicion for organic cause based on history and exam
- Testing
- Fluorescein stain the Cornea for Corneal Abrasion
- Stool Guaiac
- Urine Toxicology Screening
- Serum chemistry panel (including Serum Sodium, Serum Calcium)
- Consider Sepsis evaluation
- Consider head imaging
IX. References
- Behar, Claudius and Painter in Herbert (2014) EM:Rap 14(12): 7-9
- Freedman (2009) Pediatrics 123(3):841-8 [PubMed]
- Roberts (2004) Am Fam Physician 70:735-42 [PubMed]
