Irritable infant Flashcards
DDX for irritable infant
Normal crying for age - hunger, physical discomfit, tiredness Cow's milk protein intolerance Gastro-Oesophageal reflux Infection eg meningitis Intussusception Injury e.g. non accidental Other source of pain Acute onset *: UTI, otitis media, raiseICP, Hair tourniquet of fingers or toes, Corneal FB/Abrsion, Incarcerated inguinal hernia.
Red flags in an irritable infant that suggest a severe cause instead of colic
Fever lethargy Poor feeding Less responsive socially Poor wt gain Sudden onset maternal and family psychosocial state (Shaken baby syndrome)
Things to ask about in an irritable infant
feeding
temperature
change in behaviour or
social responsiveness
Other symptoms that suggest serious disease - vomiting, lethargy, poor Wt gain.
Don’t forget to examine testicular torsion or incarcerated inguinal hernia
What is a abnormal amount of time for a baby to cry
> 3hr/day for >3day/week.
Clinical characteristics of a colic baby
crying develops in the early weeks of life and peaks around 6-8 weeks of age
usually worse in late afternoon or evening but may occur at any time
may last several hours
infant may draw up legs as if in pain, but there is no evidence that colic is attributable to an intestinal problem or wind
usually improves by 3 - 4 months of age
what would support excessive tiredness as a cause of crying baby
If baby was getting 1.5hrs at a time and 3m old >2hrs awake.
What suggests hunger as a cause
this is more likely if a mother reports her baby has frequent feeds (i.e. less than 3 hrly), poor wt gain and inadequate milk supply
What suggest Cow milk or soy protein allergy as cause
Delayed non-IgE mediated reactions.
suspect if there is vomiting, blood or mucus in diarrhoea, poor weight gain,
family history in first degree relative or signs of atopy (eczema / wheezing), significant feeding problems (especially worsening with time)
Dx is made by tx for 2 wks
Mx of cow milk or soy protein allergy
eliminating cow milk by modifying the mother’s diet or changing to an extensively hydrolysed formula for a period of 2 weeks
What suggest gastro-oesophageal reflux as a cause
> 4 times per day vomiting
or if baby has feeding difficulties.
Not necessary associated with crying baby
May be secondary to cowlick/soy intolerance.
Tx not shown to affect crying.
Tx of Gastro-oesophageal reflux
Ranitidine
Omeprazole
Mx of irritable infant
Is there Vomiting diarrhoea eczema failure to thrive feeding difficulties Yes - consider cow milk allergy/Reflux and trail cow milk free formula or maternal diet. No - medical cause unlikely. Think tired, hungry, unable to self soothe. Discuss normal sleep and crying, discuss settling techniques, maximise parental support and arrange follow up.
DDX for acute onset of irritability infant
UTI Otitis media Raised intracranial pressure Hair tourniquet of fingers/toes Corneal foreign body/abrasion Incarcerated inguinal hernia
Ix for acute onset irritability
Urine MCS (if acute and vomiting) Fluorescein staining of eyes if hx suggestive
Mx of crying baby when excluded medical causes
- Engage partnership with parents
- Explain normal crying and sleep patterns, signs of tiredness
- Assist parents to help their baby deal with discomfort and distress.eat settling, sleep. avoid stimulation, baby massage, dental music,
- Assess maternal and emotional state and mother baby relationship (PND)
- Provide information sheets.
Followup and refer.
MX of infantile colic
Education for mother
Resolves after 3 months
No long term complications
Avoid overfeeding, wind carefully, rhythmical rocking or carrying can help.
Recommend social support for mum in the mean time.
Symptoms and signs of intussusception
Intermittent screaming/colic \+/- legs drawn up Shock/pallor Vomiting - bile stained is late Red currant jelly stool Diarrhoea Usually 3-24 months old may have a viral infection prior Sausage shape mass in abdominal in RUQ
Ix and findings for intussusception
AXR - rounded edge of the intussusception against the gas filled lumen of distal bowel with signs of proximal bowel obstruction
USS - doughnut sign - presence of bowel in bowel
Blood group and hold
Mx of intussusception
IV access Resus if needed 20ml/kg NS Analgesia Nil by mouth \+/- NGT and ABX Air or barium enema If fail then laparotomy
Symptoms and signs of strangulated inguinal hernia
Common in preterm infants
HX of intermittent inguinoscrotal bulge with associated irritability.
Often increase in size when the child is crying
Painful
Swelling extends up into the groin, does not transilluminate
Tesis is palpable, distinct from the swelling
Firm
Irreducible
Mx of strangulated inguinal hernia
Surgical emergency
IV access
Symptoms and signs of testicular torsion
Sudden onset Tender swollen scrotum Intense pain ~Nausea Occurs in pubertal boys Discolouration of scrotum very tender Swollen Riding high Cremasteric reflex absent
Mx of testicular torsion
Surgical emergencies (8-12hr)
Keep child fasted
Group and hold
Signs of non accidental Injury
Bites
Hidden head injuries
Suspicious fracture
explanation of injury is unconvincing
Delay in obtaining medical advice
Multiple injuries sustained at different times
Bruise except on toddlers leg. look at shape and colour
Burns and scalds - e.g. symmetrical without splash marks or cigarette burn e.g. deep circular ulcers
Retinal haemorrhages eg shaken body
Signs of neglect
Signs of non accidental injury
child is wary or over affectionate towards examiner
Fail to thrive
Signs of sexual abuse
Genital examination - bruises tears or nothing at all.
Pregnancy
STI
Signs of physical neglect
Unkempt dirty appearance
sores
uncared for nappy rash
Failure to thrive
Signs of emotional abuse
Frozen, watchful appearance
Expressionless face, wary eyes
Abnormally affectionate to strangers
