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Essentials - Pediatrics > 5. Inconsolable Crying (Crying or Fussing Child) > Flashcards

5. Inconsolable Crying (Crying or Fussing Child) Flashcards

1
Q

Normal crying patterns: on average ___ h/d by 6 wk of age

A

3 h/d by 6 wk of age

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2
Q

When’s the Peak crying time?

A

15:00 to 23:00

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3
Q

Etiology of colic remains unknown. Name possible causes (4)

A

GI dysfunction

  • cow’s milk protein allergy
  • malabsorption
  • GI dysmotility
  • headaches
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4
Q

Describe: Infantile Colic (5)

A
  • Benign, self-limited condition
  • It is a Dx of exclusion.
  • Begins in the first weeks of life, and peaks during the 2nd to 3rd month
  • First few weeks of life are unremarkable, and infant is normal when not “colicky.”
  • Seen equally in both sexes, across cultures, and breast-fed and bottle-fed infants.a
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5
Q

Name DDx of prolonged crying by system: General (2)

A
  • Drug ingestion/overdose
  • Hunger, colic, discomfort
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6
Q

Name DDx of prolonged crying by system: Skin (5)

A
  • Tourniquet (digit or penis)
  • Pinching of skin—diaper pin
  • Atopic dermatitis
  • Burns (accidental/nonaccidental)
  • Bite/stings
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7
Q

Name DDx of prolonged crying by system: Eyes (3)

A
  • Foreign body
  • Glaucoma
  • Corneal abrasion
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8
Q

Name DDx of prolonged crying by system: ENT (3)

A
  • Otitis media
  • Nasal congestion
  • Thrush
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9
Q

Name DDx of prolonged crying by system: Cardiovascular (3)

A
  • Heart failure
  • Supraventricular tachycardia
  • Myocarditis
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10
Q

Name DDx of prolonged crying by system: Chest (6)

A
  • Hypoxia
  • Hypercarbia
  • Pneumonia
  • Broncholiolitis
  • Acute airway obstruction (croup/foreign body, asthma)
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11
Q

Name DDx of prolonged crying by system: GI (8)

A
  • Diarrhea/constipation
  • Intussusception
  • Anal fissure
  • Inguinal hernia
  • Volvulus/malrotation
  • Gastroesophageal reflux
  • Peritonitis
  • Intestinal obstruction
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12
Q

Name DDx of prolonged crying by system: Genitourinary (4)

A
  • Urinary tract infection
  • Urinary tract obstruction
  • Torsion of testes or ovaries
  • Nephrolithiasis
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13
Q

Name DDx of prolonged crying by system: Skeletal (4)

A
  • Trauma-fracture
  • Osteomyelitis
  • Subluxation/dislocation
  • Nonaccidental injury
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14
Q

Name DDx of prolonged crying by system: CNS (4)

A
  • Meningitis/encephalitis
  • Abusive head injury
  • Epilepsy
  • Degenerative condition
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15
Q

Name DDx of prolonged crying by system: Toxic-metabolic (4)

A
  • Ingestion
  • Electrolyte abnormality
  • Inborn error of metabolism
  • Hyperthyroidism
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16
Q

Describe HX: Inconsolable Crying (10)

A
  • Detailed crying Hx
    • Length of time, timing of crying, progression/worsening, pattern of crying, alleviating/precipitating factors, any other symptoms associated with crying (fever, vomiting, increased sleepiness, drawing up legs to abdo, difficulty breathing), any trauma, lumps or bumps noticed (hernia)
  • Pregnancy/birth Hx: prenatal care, problems during pregnancy, alcohol/drug use, GBS status (bacterial meningitis), gestational age, type of delivery, complications after birth, BW
  • Nutrition/development: feeding (breast or bottle), how frequent, cyanosis with feeds, diaphoresis with feeds (cardiac condition)
  • Stooling: frequency, appearance of stool, blood in stool, crying associated with stooling or around stooling
  • Voiding: number of diapers per day (hydration status), foul smell, or color change of urine (UTI)
  • Sleeping patterns: hours per day, wakes to feed, seems content, has alert periods through the day
  • General development: no regression in milestones achieved
  • PMHx/medication: any medical conditions, visits to emergency room, medications (including herbal medications, supplements), allergies, immunization status
  • FHx: draw pedigree
  • SHx: extremely important to assess coping of parents to rule out abuse or abusive head trauma as an etiology for crying
    • Maternal age, paternal age, involvement in care of child
    • Living situation
    • Support system for parents (family/other)
    • Financial situation
    • Parents’ sleep (hours of sleep, feeling tired)
    • Parents’ mood (crying, feelings toward child—screen for depression)
    • Other concerns from parents/mom
17
Q

Describe physical exam: Inconsolable Crying (9)

A
  • Vital signs: tachycardia, fever
  • General: does the child appear sick unwell or well? Disposition—lethargic, paroxysmal irritability (meningitis/encephalitis)
  • Anthropometrics: plot growth parameters on WHO growth curve
  • HEENT:
    • Skull: swelling, tenderness, skull depression (trauma)
    • Fontanelle: sunken (hydration status), bulging/full (meningitis/intracranial process), large fontanelle (hydrocephalus), closed (craniosynostosis)
    • Ears: discharge, erythematous tympanic membrane, loss of landmarks, effusion, bulging (otitis media), contusion to external ear (nonaccidental injury)
    • Eyes: sunken (hydration status), red reflex (absent—tumor, retinal detachment), pupillary size/reflex, corneal enlargement (glaucoma), discharge or tearing (infection, allergy, glaucoma)
    • Oropharynx: thrush, vesicular lesions
  • Cardiac: central and peripheral pulses (bounding vs. weak), capillary refill time, heart sounds (S1 + S2, muffled sounds, additional sounds, murmurs)
  • Respiratory: increased work of breathing—tachypnea (bronchiolitis, pneumonia, foreign body), bradypnea (head trauma, ingestion), auscultation—wheezing (asthma, bronchiolitis), air entry (pneumonia)
  • Abdo: distention/masses—sausage shape abdo mass (intussusception), bowel sounds
  • GU: rashes in diaper/genital area, anal fissures, bulging in groin/umbilicus (in- carcerated or strangulated hernia), hair tourniquet, if male: retracted foreskin, cremasteric reflex (torsion)
  • Skin/MSK: rashes, bruising, painful extremities on palpation/deformation of extremities, swollen/red joints (osteomyelitis)
18
Q

Describe investigations: Inconsolable Crying (6)

A
  • Routine investigations are not warranted for crying infants, unless guided by specific indicators on Hx or physical exam. Investigations may include:
    • CBC: leukocytosis, signs of infection
    • Electrolytes, glucose: metabolic disturbance
    • Urinalysis: UTI, RTA
    • ECG: CHF or ALCAPA
    • CXR: if considering intrathoracic pathology
    • Other investigations include: urine ± blood cultures, toxicology screen if considering ingestion, abdo plain lms or U/S, skeletal survey
19
Q

Name Emergencies to Rule Out when inconsolable crying (8)

A
  • Hair tourniquet: remove tourniquet immediately and ensure blood flow returns to area
  • Testicular torsion: U/S doppler, referral to urologist immediately, transfer to center where pediatric urologist available if high index of suspicion
  • Glaucoma: referral to an ophthalmologist
  • Malrotation/volvulus: Abdo plain films, general surgery consultation
  • Intussusception: Abdo U/S, air enema, surgical consultation
  • Incarcerated/strangulated hernia: Dx based on exam, inability to reduce hernia, consider U/S, general surgery consultation
  • Septic arthritis: consider joint aspiration if clinical exam suspicious, start antibiotics early
  • Abusive head trauma: head imaging, skeletal survey, involve child services and team that deals with suspected cases of abuse
20
Q

Describe management of inconsolable crying (5)

A
  • Counsel caregivers of fussy/crying children without organic disease. Select children who require follow-up for additional investigations or referral to specialist.
  • Management of Colic
  • Dietary Changes
  • Supplements and Medications
  • Alternative Therapies
21
Q

Describe: Management of Colic (4)

A

Parental support/education:

  • acknowledgement of frustrations
  • education
  • encouraging taking breaks from crying infant.
  • Offer to provide social resources or closer follow-up if concerned about parental well-being
22
Q

Name Dietary Changes for Breast-fed infants for inconsolable crying (1)

A

hypoallergenic diet in mother (milk, egg, wheat, nut, fish, soy free) may reduce colic in some infants, although conflicting evidence.

23
Q

Name Dietary Changes for Formula-fed infants for inconsolable crying (2)

A
  • hypoallergenic formula (hydrolyzed casein/whey protein and amino acid based) may be effective in reducing colic in formula-fed infants.
  • Soy- based formula may reduce symptoms of colic in some infants; however, this is not recommended because of common allergen in infancy.
24
Q

Name Supplements and Medications (2)

A
  • Probiotics and prebiotics: insufficient evidence for or against use in the treat- ment of colic. May show some improvement in breast-fed infants. More studies needed—no adverse effects identified.
  • Simethicone has not been shown to have benefit.
25
Q

Name and describe Alternative Therapies for inconsolable crying (3)

A
  • Manipulative therapies: gentle manipulative techniques used in osteopathy and chiropractic therapies—not safely established. Cannot draw conclusions regard- ing these techniques.
  • Acupuncture: conflicting results. Not recommended as treatment.
  • Swaddling: current evidence base does not support use of swaddling for management of infantile colic.

Essentials - Pediatrics (20 decks)

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