INCONSOLABLE Crying Child

INCONSOLABLE Crying Child

Epidemiology 

Inconsolable crying children can be troublesome for parents and emergency department doctors , especially in the middle of the night.A comprehensive management is needed to determine the cause and provide the proper relief to the child.

Differential Diagnosis

1.Common Causes of an inconsolably Crying Infant

• Infantile colic
• Corneal Abrasion or eye foreign body
• Hair tourniquet (hair strangulating appendage)  eg at finger, toe, penis
• Teething
• Insect Bite

2.Gastrointestinal Causes

• Constipation
• Cow's Milk Protein Intolerance (peaks at 13 weeks)
• Pediatric Gastroesophageal Reflux
• Acute Gastroenteritis
• Lactose Intolerance
  Uncommon in young infants, but may present with Diarrhea and reducing substances in stool
• Anal Fissure
• Intussusception (especially over age 3 months)
• Intestinal Malrotation and Midgut Volvulus
• Incarcerated Hernia

3.Infectious Causes

• Urinary Tract Infection
• Otitis Media
• Pharyngitis
• Pneumonitis
• Sore Throat

4.Miscellaneous serious Causes

• Meningitis
• Trauma (e.g. Fracture, Subdural Hematoma): ConsiderChild Abuse (non-accidental Trauma)
• Testicular Torsion (especially if Undescended Testicle)
• Drug Ingestion

Organic cause is found in 5% of cases (with Urinary Tract Infection most common, especially <1 month old)

Precautions

1. Infantile Colic is a diagnosis of exclusion

• Normal physical exam
• Colic should follow rule of 3s
  - Limited to age 3 weeks to 3 months (peaking at 6 weeks, and resolves by 4 months in 90% of   cases)
  - Three hours of crying for at least 3 days per week, occurring later in the day (after 3pm)

2. Stranger anxiety is a diagnosis of exclusion

• Does not start until age 8 to 9 months
• Should not obviate a thorough evaluation for serious cause

3. Consider parental factors

• Postpartum Depression

Examination

1. Obtain Vital Signs (Heart Rate, Blood Pressure)
   - Evaluate for Supraventricular Tachycardia
   
   
2. Obtain a body weight and plot against an expected weight (identify Failure to Thrive)
3. Undress the infant and perform a complete examination for organic cause
4. Fontanelle (bulging Fontanelle may suggest Meningitis)
5. Eyes for foreign body (e.g. eye lash) or Corneal Abrasion, and consider Retinal Exam Corneal - Abrasions are common (as many as half of asymptomatic infants) 
   - Continue to look for other causes of Unconsolable Crying even after Corneal Abrasion is found
   
   
6. Ears for Otitis Media
7. Nose for obstruction (suctioning may clear)
8. Mouth for Stomatitis, Thrush or nonaccidental Trauma (frenulum tear)
9. Lung Exam for respiratory disease
10. Cardiovascular exam for perfusion and pulses (consider Heart Failure)
11. Abdominal exam for acute abdominal sign 
    - Examine for abdominal mass (e.g. Intussusception) 
    - Examine for blood in the stool (e.g. Anal Fissure)
    
    
12. Genitourinary exam 
    - Incarcerated Hernia 
    - Testicular Torsion
    
    
13. Neurologic Exam
14. Musculoskeletal Exam
    Joint exam for Septic Arthritis, Osteomyelitis
    General exam for signs of Trauma or Fracture (consider Child Abuse) 
                           - Bruising 
                           - Decreased extremity use
15. Skin Exam
16. Evaluate for Hair Tourniquet

Investigation

1. No single battery of lab tests is recommended for Unconsolable Crying

• Testing should only be performed as indicated based on history and exam
• Lab abnormalities are identified in only 14% of Unconsolable Crying

2. Catheterized Urinalysis

• Evaluate for Urinary Tract Infection when other etiology for Unconsolable Crying is not identified
• Obtain especially for excessive crying under 1 month of age (10% have UTI)

Red Flags: Suggest Organic Cause

1. Symptoms

• Apnea
• Cyanosis
• Shortness of Breath
• Persistent Unconsolable Crying during a 1-2 hour Emergency Department evaluation

2. Signs

• Lethargy
• Tachypnea
• Decreased Capillary Refill
• Poor weight gain or weight loss
• Fever > 100.4 F

Evaluation: Second Line

1.Indications

• Red-flag findings (e.g. persistent Unconsolable Crying in ED)
• Other suspicion for organic cause based on history and exam

2.Testing

• Fluorescein stain the Cornea for Corneal Abrasion
• Stool Guaiac
• Urine Toxicology Screening
• Serum chemistry panel (including Serum Sodium, Serum Calcium)
• Consider Sepsis evaluation
• Consider head imaging

Inconsolable crying children usually require admission for further observation in pediatric ward.