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Irritable Infant, Emergency Medicine

Basics

Description

- Address life-threatening/serious causes of irritability first: - Cardiovascular: Supraventricular tachycardia, congestive heart failure, endocarditis/myocarditis - Neurologic: Subdural/epidural, meningitis, intracranial hemorrhage, increased intracranial pressure, skull fracture - Gl: Volvulus, intussusception, appendicitis, peritonitis - Metabolic: Metabolic acidosis, electrolyte disturbances - Genitourinary: UTI, torsion of testis, incarcerated hernia - Pulmonary: Foreign body, pneumothorax, pneumonia - Dermatologic: Strangulated digit - Toxicologic: Toxic ingestion, immunization reaction - Trauma - Ophthalmologic: Corneal abrasion, glaucoma - Other: Child abuse, transplacental passage of maternal medications that may cause irritability

  • Most children have some period of the day when they are most irritable, usually toward the evening:Normal infant crying ranges from 1 " “4 hr by 6 wk of age.During the 1st 6 mo of life, 1 mo olds have the highest prevalence of crying
  • Irritability is based on a comparison with the childs normal behavior pattern
  • Colic is the most common cause of inconsolable crying in infants, occurring in as many as 25% of healthy children:Episodes of paroxysmal screaming accompanied by drawing up knees and oftentimes passage of flatusUsually begins at 2 " “3 wk and may continue through 12 wkDiagnosis of exclusion

Etiology

  • Bites: Spider/insect bite
  • Burn
  • Cardiac (supraventricular tachycardia, congestive heart failure, aberrant left coronary artery, coarctation of the aorta, endocarditis, myocarditis)
  • Child abuse
  • Corneal abrasion/foreign body (eyelash) in eye
  • Diaper pin
  • Diphtheria, pertussis, and tetanus (DPT) and other vaccine reactions
  • Endocrine/metabolic (inborn errors of metabolism, metabolic acidosis, hypernatremia, hypoglycemia, hypocalcemia, hyperthyroid " ”direct or by transplacental passage of maternal thyroid stimulating immunoglobulins)
  • Foreign body, fracture, tourniquet (hair around digit or penis)
  • Gl (gastroenteritis, colic, gastroesophageal reflux, esophagitis, volvulus, malrotation constipation, cows milk protein intolerance, anal fissure, intussusception, appendicitis)
  • Genitourinary (incarcerated hernia, testicular torsion, genital tourniquets, urinary retention)
  • Iron deficiency/anemia
  • Medications/toxins: Aspirin, antihistamines, atropine, adrenergics, home remedies, new prescription, mercury)
  • Meningitis
  • Minor acute infections (upper respiratory infection, otitis media, thrush, gingivostomatitis)
  • Neurologic (increased intracranial pressure: Mass, hydrocephalus, intracranial hemorrhage, hematoma " ”subdural, epidural, skull fracture)
  • Osteomyelitis
  • Parental anxiety
  • Pneumonia
  • Sickle cell crisis
  • Splinter
  • Teething
  • Trauma
  • UTI
  • Vascular

Diagnosis

Signs and Symptoms

  • Vital signs
  • Chief complaint
  • Chronology of events

History

Obtain complete history (including neonatal history) and information regarding routine feeding, crying. ‚

Physical Exam

  • Assess vital signs including rectal temperature and pulse oximetry.
  • Measure and plot for percentiles: Height, weight, and head circumference.
  • Perform a thorough physical exam with infant completely undressed.

Essential Workup

This is usually directed by a comprehensive history and physical exam. Specific studies may be obtained. ‚

Diagnosis Tests & Interpretation

Lab

  • CBC, urinalysis, chemistries, and cultures as indicated by history and physical exam
  • Stat blood glucose at bedside if indicated.
  • Stool hemoccult test if GI signs or symptoms

Imaging

  • Chest radiograph to exclude cardiopulmonary disease
  • Skeletal survey, if indicated
  • CT scan of the head, chest, etc. usually directed by history and physical exam
  • Contrast radiograph studies such as barium enema for specific indications

Diagnostic Procedures/Surgery

Differential Diagnosis

See etiology above. It is essential to distinguish benign, self-limited conditions from those that might be life threatening. ‚

Treatment

Pre-Hospital

As determined by history, physical exam, and lab studies ‚

Initial Stabilization/Therapy

  • Manage underlying conditions; stabilize airway, breathing, and circulation (ABCs).
  • Immediate removal of hair tourniquets and/or splinters

Ed Treatment/Procedures

  • Initial evaluation of the child focusing on parent " “child interaction and then on potential underlying conditions
  • Colic responds to soothing, rhythmic activities, avoiding stimulants (coffee, cola), minimizing daytime sleep:Soy or hydrolyzed casein formula may be transiently beneficial.Parents must reduce stressNo proven pharmacologic therapyProbiotics may be useful
  • Support, empathy, close follow-up
  • Prolonged observation of the child is usually appropriate.

Medication

Dependent on the underlying condition ‚

First Line

Dependent on the underlying condition ‚

Second Line

Dependent on the underlying condition ‚

Follow-Up

Disposition

Admission Criteria

  • Life-threatening underlying condition
  • Significant parental stress secondary to crying infant

Discharge Criteria

  • No serious condition
  • Functional and supportive family
  • Excellent follow-up is essential; parents must feel that their observations and concerns are not being ignored. Close follow-up and ongoing observation are mandatory to reevaluate the child and provide support to the family.

Issues for Referral

Determined by specific specialty related issues ‚

Followup Recommendations

Long-term follow-up strongly recommended ‚

Pearls and Pitfalls

  • Address life-threatening/serious causes of irritability first:Cardiovascular: Supraventricular tachycardia, congestive heart failure, endocarditis/myocarditisNeurologic: Subdural/epidural, meningitis, intracranial hemorrhage, increased intracranial pressure, skull fractureGl: Volvulus, intussusception, appendicitis, peritonitisMetabolic: Metabolic acidosis, electrolyte disturbancesGenitourinary: UTI, torsion of testis, incarcerated herniaPulmonary: Foreign body, pneumothorax, pneumoniaDermatologic: Strangulated digitToxicologic: Toxic ingestion, immunization reactionTraumaOphthalmologic: Corneal abrasion, glaucomaOther: Child abuse, transplacental passage of maternal medications that may cause irritability
  • Detailed history and complete physical exam in the noncritically ill child is crucial before obtaining any lab or radiologic studies

Additional Reading

  • Benjamin ‚ JS, Chong ‚ E, Ramayya ‚ MS. A preterm, female newborn with tachycardia, hypertension, poor weight gain, and irritability. Clin Pediatr (Phila). 2012;51(10):994 " “997.
  • French ‚ LK, Campbell ‚ J, Hendrickson ‚ RG. A hypertensive child with irritability and a rash. Pediatr Emerg Care. 2012;28(6):581 " “583.
  • Garrison ‚ MM, Christakis ‚ DA. A systematic review of treatments for infant colic. Pediatrics. 2000;106(1 pt 2):184 " “190.
  • Herman ‚ M, Le ‚ A. The crying infant. Emerg Med Clin North Am. 2007;25:1137 " “1159.
  • Hiscock ‚ H, Jordan ‚ B. 1. Problem crying in infancy. Med J Aust. 2004;181(9):507 " “512.
  • Pawel ‚ BB, Henretig ‚ FM. Crying and colic in early infancy. In: Fleisher ‚ GR, Ludwig ‚ S, eds. Textbook of Pediatric Emergency Medicine. 6th ed. Philadelphia, PA: Lippincott; 2010.
  • Swischuk ‚ LE. Irritable infant and left lower extremity pain. Pediatr Emerg Care. 1997;13(2):147 " “148.
  • Ward ‚ TR, Falconer ‚ JA, Craven ‚ JA. An irritable infant and the runaway redback: An instructive case. Case Rep Emerg Med. 2011;2011:125740

Codes

ICD9

  • 780.91 Fussy infant (baby)
  • 780.92 Excessive crying of infant (baby)
  • 789.7 Colic

ICD10

  • R10.83 Colic
  • R68.11 Excessive crying of infant (baby)
  • R68.12 Fussy infant (baby)

SNOMED

  • 444951002 fussy infant (finding)
  • 162214009 Crying infant (finding)
  • 35363006 Infantile colic (finding)
  • 247361008 Evening colic (finding)