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An Evidence-Based, Systematic Approach To Acute, Unexplained, Excessive Crying In Infants

February 2005

Abstract

Infants cry more during their first 4 months than at any other time of life. Brazelton defined "normal" infant crying as 1 hour and 45 minutes at age 2 weeks, a peak of 2 hours and 45 minutes at age 6 weeks, decreasing to less than 1 hour at age 12 weeks. He also described a diurnal variation, with peak crying time from 3 pm to 11 pm.1 Wessel et al and Illingsworth had earlier described excessively crying infants as having "colic," from the Greek for colon, because of the associated symptoms of grimacing, abdominal distention, and flatulence.2,3 Crying is the primary form of nonverbal communication for neonates and infants and is the principle means by which they express needs, anger, and frustration. William Dewees in 1825, in his Treatise on the Physical and Medical Treatment of Children, refers to crying as "...not always expressive of pain; it is intended very often as an appeal to the tenderness of the mother, when the child is impelled to make its necessities known hunger and thirst, or sometimes, upon much more important occasions to itself, namely uneasiness..."4 Parents respond to their crying infants in a variety of ways. Most parents develop an intuitive sense for their infant's needs and report that they can distinguish differences between crying associated with hunger and discomfort and the fussiness that accompanies fatigue or boredom. Parental response to crying is dependent upon their ability to cope with differing levels of crying intensity and duration, as well as their perception of what is "normal" or "abnormal" crying. By the time the parents present to the ED with their crying infant, most have exhausted their repertoire of consoling responses. Often the parents are anxious, frustrated, and sleep deprived. Many parents, especially mothers, have guilt feelings related to their parenting abilities because they have been unable to adequately console their baby. All of these conflicting emotions add to the difficulty of evaluating the nonverbal, uncooperative patient.

This issue of Pediatric Emergency Medicine Practice will present a systematic approach to the infant with acute, excessive crying in the ED setting. A summary of the pertinent past and current literature concerning crying syndromes and a detailed discussion of the differential diagnosis of pathologic conditions, of which crying may be a presenting or secondary complaint, will provide a basis for the evaluation and disposition of a subset of very challenging patients.
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