Basics
Description
- 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 flatus
- Usually begins at 2 " “3 wk and may continue through 12 wk
- Diagnosis 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 stress
- No proven pharmacologic therapy
- Probiotics 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/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
- 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)