A Systematic Approach To The Evaluation Of Acute Unexplained Crying In Infants In The Emergency Department

Table of Contents

 

1. Abstract
2. Case Presentation
3. Introduction
4. Critical Appraisal Of The Literature
5. Etiology And Epidemiology
6. Differential Diagnosis
   1. Life-Threatening Causes Of Crying
      1. Nonaccidental Trauma And Crying
   2. Common Causes Of Crying
   3. Clinical Clues To Differentiate Serious Illnesses From Less-Serious Illnesses
      1. Heightened Parental Concern
      2. Heightened Clinician Concern
      3. Objective Patient Variables
7. Prehospital Care
8. Emergency Department Evaluation
   1. History
   2. Physical Examination
      1. Initial Impression And General Appearance
         • Observation Period
         • Inconsolability
      2. Head And Neck
         • Corneal Abrasions
         • Acute Otitis Media
         • Nonaccidental Trauma
         • Oropharyngeal Pathologies
      3. Thorax
         • Clavicular Fractures
         • Vertebral Osteomyelitis And Discitis
         • Rib Fractures
         • Mastitis
      4. Heart And Cardiovascular System
         • Arrhythmias
         • Congenital Heart Disease And Heart Failure
      5. Abdomen
         • Constipation
         • Hirschsprung Disease
         • Pyloric Stenosis
         • Malrotation With Volvulus
         • Intussusception
      6. Genitourinary System
         • Occult Urinary Tract Infection
         • Inguinal Hernias
      7. Extremities
         • Septic Arthritis
         • Fractures
      8. Nervous System
         • Hypoglycemia/Nervous Irritability
         • Central Nervous System Infections
         • Occult Head Injury
      9. Skin
         • Ecchymoses
         • Burns
9. Diagnostic Studies
   1. Laboratory Testing
   2. Imaging
   3. Serial Examinations
   4. Follow-Up As A Key To Diagnosis
10. Treatment
11. Special Circumstances
    1. Crying Without A Clear Cause: Crying, Colic, And Concerned Parents
12. Disposition
13. Summary
14. Risk Management Pitfalls For Acute Unexplained Crying In Infants
15. Clinical Pathway For Evaluation Of Acute Unexplained Crying In Infants
16. Time- And Cost-Effective Strategies
17. Case Conclusions
18. Tables
    1. Table 1. Differential Diagnosis For Acute Unexplained Crying In Infants
    2. Table 2. Patient History Of Illness
    3. Table 3. Disposition Criteria For Crying
19. References

Abstract

Crying is a common behavior of infancy that can be a signal of a broad spectrum of conditions ranging from the normal needs of hunger and sleep to significant medical or surgical pathology. In the medical setting, crying is often seen in concert with other signifiers of disease or distress, such as fever, vomiting, rash, or trauma. However, challenges in evaluation of infants may arise when crying is the only sign. A thorough, systematic, and appropriate history and physical examination are needed. Additionally, a broad range of medical possibilities coupled with caregiver concern need to be considered to ensure proper evaluation. In this issue, we will review crying as a chief complaint in the emergency department setting and provide a systematic and practical approach to the evaluation of crying infants.

Key words: Infant, crying, inconsolability, irritability, colic, parental concern, urinalysis, serial examination, nonaccidental trauma

Case Presentation

Joseph is a 4-month-old boy whose parents bring him to the ED after 2 weeks of intermittent episodes of fussiness and crying that became more frequent and are now being described as “constant.” He was seen by his pediatrician earlier in the week and was started on oral ranitidine for presumed gastroesophageal reflux. However, the family feels this recent crying is not consistent with the pattern of crying that he exhibited prior to starting the antireflux medication. He has had no fever, vomiting, or diarrhea. He has been taking in a normal amount of liquids orally with a normal volume of urine output and 3 to 4 mustardy yellow stools per day. The mother had an uncomplicated pregnancy and delivery. He was a full-term infant and has been growing well. He has no risk factors for sepsis. His physical examination is completely unremarkable, with normal vital signs for his age. He is well-appearing, calm, quiet, and in no distress during the initial history and examination. You consider the following: Could there be a connection between Joseph’s crying and the recent diagnosis of gastroesophageal reflux? Do the parents’ concerns about the change in their baby’s crying pattern affect your concern as a clinician? If the baby now appears well and is afebrile with a normal examination, is any further testing necessary at this time?

Melissa is a 10-week-old girl born by normal spontaneous vaginal delivery, at term, with no complications. She is brought to the ED by her mother with a chief complaint of being “inconsolable.” Per her mother’s report, she had been in her usual state of health until her 2-month well-child visit 3 days ago, when she received her scheduled vaccinations. She was slightly “fussy” after getting the vaccinations. She developed a low-grade temperature to 37.9°C that night, but slept well and, by the next morning, was afebrile. Yesterday, she was given a bath and a few hours later began to cry intermittently. Over the course of the following 24 hours, she became increasingly irritable and is now inconsolable. Her mother denies that her daughter has cough, rhinorrhea, rash, vomiting, diarrhea, decreased oral intake, or change in urine output, but she has had some difficulty sleeping over the past 24 hours. The mother states that she has 3 other children at home and does not have any support socially or financially, as the father of this baby is not currently involved. She admits to feeling overwhelmed. On initial examination, Melissa is intermittently crying, but consolable, and has no revealing findings. Vital signs are within normal limits other than some mild tachycardia that you attribute to her crying. The vaccination sites on her bilateral thighs are without induration or tenderness to palpation. Despite the unrevealing examination, you have a “gut feeling” that something is wrong with Melissa. You tell the mother that you will observe her in the ED and will return shortly to check her again. You consider the following: In the setting of recent vaccinations, could this be an adverse reaction, even 3 days after administration? What about this history is giving you such a bad gut feeling, and how should you integrate this concern into your evaluation, if at all?

Introduction

Crying is the sole method of communication for infants. There is an extensive body of medical literature describing its physiology, progression, variations, and parental and caregiver responses. Crying can reflect that an infant's basic needs (such as hunger, thirst, and the need for affection) are unmet, or it can represent significant distress (anger, discomfort, and pain).¹ While crying remains a well-studied phenomenon, the understanding and management of the crying infant continues to challenge parents and caregivers alike.

Parents often have an intuitive sense of why their babies are crying and can distinguish the cries of hunger, fatigue, and discomfort from one another and address those needs.^2-4 When crying patterns deviate from the perceived “norm,” (ie, are seen as excessive or uncharacteristic) or when efforts to console a crying infant are exhausted, parents will often seek help from a healthcare provider. At that point, parents may be anxious, sleep-deprived, troubled, and in need of care and reassurance themselves.

Crying as a presenting complaint is one of the most common indications for parents to seek medical attention in the first 3 months of life.⁵ It is also a prevalent presentation for evaluation in the emergency department (ED). Studies have reported a percentage of all annual ED visits for infant crying ranging from 0.25% to 13.6%.^6,7,8 Evaluating crying in preverbal patients and relating to their caregivers may be a significant challenge to emergency clinicians. Absence of fever, vomiting, respiratory distress, or other symptoms that more readily lend themselves to preestablished guidelines for evaluation and management augment the challenge. Providers must determine a timely and cost-effective strategy for evaluating these infants.

This issue will present an updated systematic approach to management of the infant who presents with acute, unexplained crying in the ED setting. This article will review pertinent literature, relevant background information, the common and more serious diagnoses, and algorithms for evaluating, treating, and determining disposition for this group of patients.

Critical Appraisal Of The Literature

A search was performed in PubMed for articles published since 1960 pertaining to children aged < 2 years, using multiple combinations of the search terms including, but not limited to: infant crying, fussiness, inconsolability, and irritability. Search terms to qualify crying patterns were also used, including prolonged, excessive, normal, abnormal, acute, and dangerous. The Cochrane Database of Systematic Reviews was also consulted. Articles relevant to infant crying were lessselected and reviewed. Over 150 articles were reviewed, 70 of which were chosen for inclusion in this review, including a number of case reports, clinical reviews, and retrospective and prospective controlled studies. The challenge in evaluating the literature on crying is the variability in defining terms applicable to crying behaviors, the multitude of clinical settings, and the dearth of large, practice-changing studies. Crying is a complaint that is not unique to the ED; therefore, a comprehensive analysis of the literature must include a broader scope of pediatric studies in a variety of clinical settings. The underlying etiologies for infant crying are often nonemergent, or not initially recognized as emergent, so crying infants are often seen in primary care offices. Of the 70 articles chosen for this article, approximately 20 to 25 of the studies were conducted in the outpatient or primary care setting, 10 were conducted in the inpatient or hospital setting, and 20 in the ED setting. The remaining articles were large-scale reviews. The data from these studies and reviews inform the general approach to the care of crying infants, including those who present for their initial care in the ED.

One of the most referenced papers is a 1991 prospective study of 56 infants performed by Poole in the ED setting.⁸ The largest North American study published in 2009 by Freedman et al retrospectively reviewed 237 infants who presented to the ED with crying.⁷ While recent reviews and larger studies help guide management of the crying infant, it remains difficult to define a centralized body of literature as well as standardized treatment algorithms for evaluating these infants.⁹

Risk Management Pitfalls For Acute Unexplained Crying In Infants

1. “The baby did not have a fever, so I did not consider that he could have a serious infection.” Sepsis and other significant infections can present as crying, alone or in conjunction with other findings. An infant may not manifest a fever as a sign of infection or, conversely, he may be hypothermic as a manifestation of infection. For a crying infant, all serious etiologies, including infection, should be considered and investigated when appropriate, with or without the presence of fever.
2. “Of course the baby had an elevated heart rate; he was crying.” Crying can often lead to tachycardia in infants. However, tachycardia can be a manifestation of infection, dehydration, evolving fever, pain, or distress. Vital signs should be taken repeatedly on a crying infant, in both the crying and noncrying state, to avoid inappropriately attributing abnormal findings to crying rather than other potentially serious underlying causes.
3. “I had a bad feeling about this baby, but how I feel shouldn’t impact my investigations.” As with parental concern, clinician concern and “gut instinct” regarding pediatric pathology has been supported as an accurate tool in determining serious illness. Emergency clinicians should acknowledge their concern and factor their intuition into an evaluation of a crying infant.
4. “The parents seem really nice, so there is no need to consider nonaccidental trauma.”Unfortunately, it is almost impossible to predict which caregivers may cause nonaccidental trauma. It must be considered in any infant with persistent or unexplained crying regardless of a family’s stature or protestations.
5. “All babies cry. This is a normal finding and is nothing to worry about.”While some amount of crying is normal in all infants, any crying that exceeds the duration or quality of the infant’s typical crying, is concerning to parents or providers, or is accompanied by a change in behavior should be considered significant and potentially pathologic until proven otherwise. The spectrum of normal crying for an infant is variable by age and by individual infant, so caregiver descriptions of deviations should be taken seriously.
6. “If I am not going to perform any diagnostic tests (such as blood, urine, imaging), I should just send this baby home. There is no reason for him to sit around in the ED.”Observation and serial examinations are paramount to the evaluation of a crying infant for whom a diagnosis is not immediately clear. This may allow for the acquisition of additional information to guide further ED testing, allow for clinicians and caregivers to follow a trajectory of illness in the ED, and provide relief for stressed caregivers and time for education.
7. “The more tests I perform, the closer I will be to making a diagnosis.” There is no one test or series of tests universally recommended for the evaluation of a crying infant. History and physical examination remain the cornerstone of diagnosis in crying infants. “Kitchen sink” testing is expensive, invasive, and inappropriate for most infants who present to the ED with acute unexplained crying.
8. “This baby just has colic.” Colic and unexplained crying are common diagnoses, but should only be applied to infants for whom other etiologies for acute crying have been considered first.
9. “This baby seems fine; there is no need for this family to follow up with their primary care provider.” Close follow-up is critical for crying infants evaluated in the ED. First, it ensures a second visit to document improvement or worsening for diagnosed conditions in which treatment may have been instituted. Second, it allows an additional diagnostic examination for infants in whom the ED visit was unrevealing and in whom an illness may now be more apparent. Lastly, it ensures a session with the primary care provider, someone who can provide reassurance and support to the family on a more long-term basis.
10. “Parents are always anxious about their babies, but it doesn’t mean anything is truly wrong with the infant.” The degree of parental concern has been shown to correlate with disease severity in infants. Parents can differentiate the cries of their infants and can intuit pathology, as well. Parental concern should be one of multiple features to factor into the evaluation of a crying infant and should not be dismissed by providers.

Tables

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.

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