Basics
Description
- Crying is usually a normal physiologic response to stress, discomfort, unfulfilled needs such as hunger, pain, over- or understimulation, or temperature change.
- Crying is felt to be potentially pathologic if it is interpreted by caregivers as differing in quality and duration without apparent explanation and/or persists without consolability beyond a reasonable time (generally 1-2 hours).
Epidemiology
- Excessive crying in the first months of life, per parental reports, occurs in about 1 in 5 infants.
Etiology
- The most likely cause of inconsolable crying in the first few months of life is infantile colic.
- However, colic is a diagnosis of exclusion.
- Practitioners must be familiar with the clinical pattern of infantile colic so that deviations are readily recognized.
- Organic problems are identified in 5% or less of afebrile excessively crying infants.
Diagnosis
History
- Question: Colic?
- Significance:
- Colic less likely as a cause if onset after 1 month of age or persistent in infants >4 months of age
- Recurrent episodes, particularly with a diurnal or evening pattern, are more likely due to colic.
- Crying shortly after feeding suggests aerophagia or gastroesophageal reflux; 1 hour after feeding suggests formula intolerance. A rare cause of postprandial crying is anomalous coronary arteries.
- Overfeeding or underfeeding, excessive air swallowing, inadequate burping, and improper formula preparation may contribute to excessive crying.
- Question: Fever?
- Significance: Indicates potential need for evaluation of meningitis, other infections
- Question: Paradoxically increased crying (attempts at consolation make the crying worse, especially with lifting, rocking)?
- Significance: Can be seen in meningitis, peritonitis, long bone fractures, arthritis
- Question: Stridor?
- Significance: Implies possible upper airway obstruction (mechanical, functional)
- Question: Expiratory grunting?
- Significance: Indicates higher likelihood of significant pathologic cause of crying (especially cardiac, respiratory, and/or infectious disease)
- Question: Cold symptoms and/or day care attendance?
- Significance: Increase likelihood of otitis media
- Question: Vomiting?
- Significance: Increases likelihood of pathologic GI cause (e.g., obstruction, gastroesophageal reflux with possible esophagitis), particularly in infant <3 months of age, or CNS disease
- Question: Recent fall or trauma?
- Significance: May indicate possible fracture, increased intracranial pressure, abuse
- Question: Documented weight loss outside of the 2-week neonatal period?
- Significance: Suggests an organic cause
Physical Exam
- Finding: Infant appears ill (e.g., pallor, grunting, poor arousability, poor response to social overtures)?
- Significance: Implies much higher likelihood of an organic cause
- Finding: Tenderness on palpation of extremities, clavicle, or scalp or painful or decreased range of motion of joints?
- Significance: Suggests fracture, subluxation, osteomyelitis, septic arthritis
- Finding: Conjunctival redness, eye tearing, scratches near the eye?
- Significance: Suggest corneal abrasion (fluorescein testing of eye warranted) or foreign body in eye (eversion of lid recommended). Cessation of crying with ophthalmic anesthetic drops while doing fluorescein staining suggests corneal injury as a cause.
- Finding: Impacted or bloody stool on rectal exam, abdominal mass?
- Significance: Suggest constipation or intussusception
- Finding: Geographic scars, frenulum tears, retinal hemorrhages, suspicious bruises, burns, decreased weight/height ratio?
- Significance: Suggest neglect/abuse (physical, emotional). Bruises are rare in preambulatory children (particularly <6 months of age); if present, consider inflicted injuries.
- Finding: Bulging or full fontanel (especially in upright, quiet infant)?
- Significance: Indicates possible increased intracranial pressure (meningitis, subdural hematoma, vitamin A toxicity)
- Finding: Edema of individual toes, fingers, or penis?
- Significance: Suggest hair tourniquet syndrome
- Finding: Tender swelling in inguinal or scrotal area?
- Significance: May indicate incarcerated hernia, testicular torsion
- Finding: Heart rate >200 bpm with minimal variability?
- Significance: Indicates possible supraventricular tachycardia
- Finding: Hypothermia?
- Significance: Suggests infections or hypothyroidism
Diagnostic Tests & Interpretation
- Test: Stool for occult blood
- Significance: Possible intussusception, anal fissure
- Test: Fluorescein testing of eye
- Significance: Corneal abrasion (may occur without significant conjunctival redness)
- Test: Urinalysis/urine culture
- Significance: UTI
- Test: Urine toxicology screen
- Significance: Drug withdrawal (neonatal), ingestions, passive exposures (e.g., cocaine)
- Test: Pulse oximetry
- Significance: Hypoxia (from cardiac causes) may cause increased irritability.
- Test: Electrolyte panel/blood glucose
- Significance: Endocrine or metabolic disturbance, especially if abnormal sodium, hypoglycemia, significant acidosis, or elevated anion gap
- Test: Skeletal survey
- Significance: Suspected abuse; also consider MRI or head CT scan for those <1 year of age with suspicious injuries
Differential Diagnosis
- Congenital/anatomic
- Intussusception
- Gastroesophageal reflux/esophagitis
- Volvulus
- Gaseous distention (secondary to improper feeding or burping)
- Incarcerated inguinal hernia
- Peritonitis (acute abdomen)
- Testicular/ovarian torsion
- Constipation
- Anal fissure
- Meatal ulceration
- Glaucoma
- Urinary retention (secondary to posterior urethral valves)
- Cardiac-anomalous coronary artery, hypoxia, congestive heart failure (CHF)
- Increased intracranial pressure (hydrocephalus, tumor, pseudotumor cerebri)
- Infectious
- Otitis media/externa
- UTI/pyelonephritis
- Stomatitis/gingivitis
- Meningitis/encephalitis
- Diskitis
- Gastroenteritis
- Mastitis
- Arthritis, septic
- Osteomyelitis
- Perianal cellulitis
- Balanitis
- Dermatitis (especially pruritic as in scabies or painful as in staphylococcal scalded skin syndrome)
- Toxic, environmental, drugs
- Neonatal drug withdrawal
- Prenatal/perinatal cocaine exposure
- Immunization reactions (especially DTP)
- Isolated fructose intolerance
- Drug reactions (especially antihistamines, pseudoephedrine, phenylpropanolamine), including maternal medications in breast milk
- Vitamin A toxicity
- Carbon monoxide exposure
- Emotional/physical neglect
- Foreign body ingestion (coin, pin)
- Ear foreign body (e.g., cockroach)
- Trauma
- Corneal abrasion
- Foreign body (hypopharynx, eye, ear, nose)
- Skull fracture/subdural hematoma
- Intracranial hemorrhage
- Retinal hemorrhage (e.g., shaken baby syndrome)
- Other fractures (especially extremities)
- Hair tourniquet syndrome (encircling finger, toe, penis, clitoris)
- Open diaper pin
- Bite (human, animal, insect)
- Genetic/metabolic
- Sickle cell crisis
- Phenylketonuria
- Hypothyroidism
- Electrolyte abnormalities (especially sodium)
- Hypoglycemia
- Hypocalcemia
- Hypercalcemia
- Inborn error of metabolism
- Allergic/inflammatory
- Cow milk allergy
- Celiac disease (gluten enteropathy)
- Hemolytic uremic syndrome
- Henoch-Sch ¶nlein purpura
- Kawasaki disease
- Functional
- Parental expectations/responses
- Miscellaneous
- Overstimulation
- Persistent night awakening
- Night terrors
- Caffey disease (infantile cortical hyperostosis)
- Dysrhythmia (especially supraventricular tachycardia)
- IV infiltration
- Autism
- Teething
- Headache/migraine
- Temperament
- Colic
- Discomfort (cold, heat, itching, hunger)
Alert
Factors that make this an emergency include the following:
- Suspicion of meningitis: stiff neck, bulging fontanel, fever (especially infants <2-3 months of age)
- Suspicion of intestinal obstruction: vomiting (especially bilious or projectile), mass on abdominal palpation, and/or bloody stools
- Suspicion of incarcerated hernia or testicular/ovarian torsion
- Evidence of cardiac compromise (CHF, supraventricular tachycardia): tachycardia, poor perfusion (capillary refill >3 seconds, poor distal pulses), rales
- Evidence of acute dehydration: weight loss, decreased urine output, orthostatic changes, poor perfusion
- Evidence of child abuse or neglect
Treatment
Approach to the Patient
General goal is to decide if the crying represents a normal physiologic response, a protracted multifactorial physiologic/developmental response (colic), or a potentially pathologic problem.
- Phase 1: How urgent is the need for evaluation? A classic and difficult triage issue. One must identify the periodicity of the problem, associated symptoms, impression of wellness, and parental anxiety/reliability.
- Phase 2: When in doubt, particularly if colic seems unlikely, see the patient as soon as possible. Treatment is then based on the most likely diagnosis following evaluation. Be wary of the infant who, despite a period of observation, is not noted at any point to be awake and calm.
Additional Reading
- Bolte R. The crying child: what are they trying to tell you? Parts I and II. Contemp Pediatr. 2007;24:74-81, 90-95.
- Douglas P, Hill P. Managing infants who cry excessively in the first few months of life. BMJ. 2011;343:d7772. [View Abstract]
- Douglas P, Hill P. The crying baby: what approach? Curr Opin Pediatr. 2011;23(5):523-529. [View Abstract]
- Freedman SB, Al-Harthy N, Thull-Freedman J. The crying infant: diagnostic testing and frequency of serious underlying disease. Pediatrics. 2009;123(3):841-848. [View Abstract]
- Herman M, Le A. The crying infant. Emerg Med Clin North Am. 2007;25(4):1137-1159. [View Abstract]
- McKenzie SA. Fifteen-minute consultation: troublesome crying in infancy. Arch Dis Child Edu Pract Ed. 2013;98(6):209-211.
- Poole SR. The infant with acute, unexplained, excessive crying. Pediatrics. 1991;88(3):450-455. [View Abstract]
Codes
ICD09
- 780.92 Excessive crying of infant (baby)
- 789.7 Colic
- 530.81 Esophageal reflux
ICD10
- R68.11 Excessive crying of infant (baby)
- R10.83 Colic
- K21.9 Gastro-esophageal reflux disease without esophagitis
SNOMED
- 304534000 Crying (finding)
- 35363006 Infantile colic (finding)
- 235595009 Gastroesophageal reflux disease (disorder)
- 30693006 Aerophagy (finding)
- 162214009 Crying infant (finding)
- 248540002 Constantly crying baby (finding)
- 95629002 Excessive crying of newborn (finding)
- 162213003 Crying excessive (finding)
FAQ
- Q: How important is lab testing in the evaluation of the crying infant?
- A: History and physical exam, rather than extensive lab testing, are the keys to the diagnosis. In Freedman's emergency department (ED) study of 237 excessively crying infants, less than 1% had testing contribute to the diagnosis in the absence of a suggestive clinical picture.
- Q: How might the quality of cry be helpful in the diagnosis?
- A: Subjective interpretation can be helpful.
- High-pitched (shrill, piercing) crying in short bursts: associated with CNS pathology, especially with increased intracranial pressure
- High-pitched crying in longer bursts: seen in small-for-gestational age infants, neonatal drug withdrawal
- Hoarse crying: seen in hypothyroidism, laryngeal diseases, hypocalcemic tetany
- Weak crying: may be seen in neuromuscular disorders, infant botulism, and/or the very ill infant
- Catlike cry: can be associated with cri du chat syndrome (5p- syndrome or absence of short arm of chromosome 5)
- Q: How common is teething as a cause of excessive crying?
- A: Patients' families often suggest teething as a cause of excessive crying (as well as fever, diarrhea, rashes, etc.). Objective data do not support a strong association. Be careful in ascribing symptoms and signs to teething.