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
2
Q
When’s the Peak crying time?
A
15:00 to 23:00
3
Q
Etiology of colic remains unknown. Name possible causes (4)
A
GI dysfunction
- cow’s milk protein allergy
- malabsorption
- GI dysmotility
- headaches
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
5
Q
Name DDx of prolonged crying by system: General (2)
A
- Drug ingestion/overdose
- Hunger, colic, discomfort
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
7
Q
Name DDx of prolonged crying by system: Eyes (3)
A
- Foreign body
- Glaucoma
- Corneal abrasion
8
Q
Name DDx of prolonged crying by system: ENT (3)
A
- Otitis media
- Nasal congestion
- Thrush
9
Q
Name DDx of prolonged crying by system: Cardiovascular (3)
A
- Heart failure
- Supraventricular tachycardia
- Myocarditis
10
Q
Name DDx of prolonged crying by system: Chest (6)
A
- Hypoxia
- Hypercarbia
- Pneumonia
- Broncholiolitis
- Acute airway obstruction (croup/foreign body, asthma)
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
12
Q
Name DDx of prolonged crying by system: Genitourinary (4)
A
- Urinary tract infection
- Urinary tract obstruction
- Torsion of testes or ovaries
- Nephrolithiasis
13
Q
Name DDx of prolonged crying by system: Skeletal (4)
A
- Trauma-fracture
- Osteomyelitis
- Subluxation/dislocation
- Nonaccidental injury
14
Q
Name DDx of prolonged crying by system: CNS (4)
A
- Meningitis/encephalitis
- Abusive head injury
- Epilepsy
- Degenerative condition
15
Q
Name DDx of prolonged crying by system: Toxic-metabolic (4)
A
- Ingestion
- Electrolyte abnormality
- Inborn error of metabolism
- Hyperthyroidism
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
Name and describe Alternative Therapies for inconsolable crying (3)
* 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.
