Crying and Irritability in the Young Child Flashcards
Serious conditions DDx to exclude for intractable crying in children
Meningitis/Encephalitis Sepsis Septic Hip Non-accidental trauma Intussusception Volvulus Appendicitis Incarcerated inguinal hernia Hemolytic Uremic Syndrome Hypoxemia Hair encirclement Testicular torsion Supraventricular tachycardia Infant botulism
Symptoms associated with each serious DDx
Meningitis/Encephalitis
- Lethargy, vomiting, paradoxical irritability, fever
Sepsis
- Lethargy, poor perfusion, fever, petechiae
Septic Hip
- pain with ROM, abnormal positioning of the hip
Non-accidental trauma
- bruising, bony tenderness, incompatible history
- lethargy, full fontanel, retinal hemorrhages
- frenulum injuries
Intussusception
- paroxysmal abdo pain, lethargy, bloody stool, abdo mass
- abnormal rectal exam
Volvulus
- bilious vomiting, abdominal tenderness
Appendicitis
- guarding of the abdomen, peritonitic signs
Incarcerated inguinal hernia
- bulge in inguinal region, skin colour change, irreducible
Hemolytic Uremic Syndrome
- bloody diarrhea, hematuria/proteinuria, hemolytic anemia, thrombocytopenia, azotemia
Hypoxemia
- tachypnea, retractions, nasal flaring, wheezing, cyanosis
Hair encirclement
- abnormal exam of digits, genitalia, uvula
Testicular torsion
- redness, swelling of scrotum, unable to palpate testes in scrotum
Supraventricular tachycardia (4%)
- nonvariable HR > 220 bpm
- can see a delta wave (widened QRS with slurred upstroke) on ECG in ASxmtc phase
Infant botulism
- constipation, hypotonia, weak cry
- weak cry is what parents notice first
Describe the features of infant colic syndrome
Cyclic discrete periods of intractable crying
Usually on a daily basis
Onset at 1-4 weeks of age
Spontaneous improvement by 3-4 months of age
Crying lasting more than 3 hours per day, 3 days a week, and continuing more than 3 weeks in infants less than 3 months of age
No V/D/poor growth is involved
What are the parameters for normal inconsolable crying
At 2 weeks –> 1.75 hours
6 weeks –> 2.75 hours
12 weeks –> <1 hour
Occurs in the evening from 3-11pm
What is a common diagnoses that can mimic colic?
Esophagitis secondary to GER
Associated with feeds, takes a few sips, then turns away and cries in pain
Or at end of feeds or 20-30 min post when lying them down
Nonforceful nonbilious vomiting
Arching
Sandifer syndrome
Other diagnoses to consider in inconsolable crying
Esophagitis secondary to GER Colic UTI Corneal abrasion UTI - even in afebrile babies, (3%, up to 10% in < 4 weeks), always send a Cx as UA can be falsely negative
What are the possible locations for a hair tourniquet and approach to treatment?
Most common - finger and toes
Also possible - penis, clitoris, uvula
Treatment
Unwinding the hair
Incising it with needle or scalpel
Chemical hair removal if no skin breakdown is present
Follow up
- important, sometimes may not get all the hair if its moved deeper into the soft tissue
- recommend parents to RTED if there is increased swelling, discoloration, or pain at the appendage
What DDx to consider when crying increases with diaper changes?
UTI
Diaper rash/discomfort
Septic hip - look for hip held in abduction, reduction in ROM, redness, swelling, pain with ROM
What is the most treatable Dx in a febrile crying infant?
UTI
Especially if female
16% in white females under 2
Name 3 relatively common life-threatening surgical emergencies of infancy you would expect crying but can sometimes be absent
Intussusception
Midgut volvulus
Shaken baby syndrome
Intussusception
- significant subset presents with isolated lethargy
- 2 mo to 2 yr range, peak at 9 mo
]- look for abdo masses and do a rectal exam (for blood)
Midgut volvulus
- abdo exam may be benign until the gut begins to infarct
- if has any bilious vomiting do an UGI series
Shaken baby syndrome
- chief complain is often lethargy or listlessness
- any facial bruising or intraoral trauma should be a redflag
