The irritable infant Flashcards
Differential diagnosis
Periodic and related to discomfort Cow's milk protein intolerance GORD Lactose overload/malabsorption Infection- ?meningitis Intussusception Injury Other sources of pain
Acute: UTI \+ICP OM Hair tourniquet Corneal abrasion Incarcerated inguinal hernia
Periodic causes
Wet/dirty nappy Too hot or too cold Hungry Wind Colic Environmental stress Reflux esophagitis Teething
Dealing with periodic
Make sure well fed, warm, has a clean nappy, comfortable clothes and a calm and peaceful environment
Infantile colic: definition, crying associated with (3), signs, (3), child in between
Periodic crying in first 3 months Paroxysmal Hunger, wind, feeding Flushed face, tense abdomen, legs drawn up Happy in between
Management of colic overview (5)
- Engage in partnership->reassurance the infant is normal and healthy
- Explain normal crying and sleep patterns
- Help parents to help their baby deal with discomfort and pain
- Assess maternal and emotional state and mother-baby relationship->coping, stress, depression
- Provide printed information
Causes of abdominal pain
GIT: Peptic ulcer Gastroenteritis Acute appendicitis->anorexia, central to RIF, peritonism, tachy IBD->blood/mucus Henoch-schonlein purpura->purpuric rash and joint pain Constipation Intestinal obstruction Mesenteric adenitis Intussusception
Urinary:
UTI
Renal colic
Endocrine:
Diabetes
Respiratory:
Lower lobe pneumonia
History in abdominal pain
Intermittent unexplained screaming Blood in stool->intussusception, IBD, HSP, gastroenteritis VD, viral, joints Anorexia Vomiting bile
What does pallor and screaming suggest
Intussusception
Examination in abdominal pain
General and vitals
Abdominal examination
Evidence of peritonism
If suspect mesenteric adenitis, palpable lymphadenopathy elsewhere
Investigations and their significance in abdominal pain
FBC->+WCC (appendicitis, UTI), anemia
Glucose->diabetes
Urine MCS->nitrates, hematuria in HSP
AXR->obstruction (dilated loops), intussusception (abnormal gas pattern), fecal loading (constipation)
Abdominal US->Renal tract abnormality, diagnosis of intussusception
CXR->pneumonia
Barium enema->intussusception
CRP/ESR->IBD
Differential diagnosis for iliac fossa pain
GIT: Mesenteric adenitis GE Constipation IBD
Other: Urinary tract infection, Pyelonephritis HSP Ovarian pain Ectopic
At what age is intussusception most common
Aged 3-24 months
Non surgical causes of acute abdominal pain
Gastroenteritis PID, ectopic UTI, pyelonephritis DKA Lower lobe pneumonia HSP
Quick treatment of mesenteric adenitis
Analgesia
Presentation of colic
Extended periods of distressed behaviour Cries ++ Repeated, sudden onset Legs drawn up, face red Worse in late afternoon and evening Both sexes Breast + bottle Abates by 3 months in 60%, 90% by 4 months
Assessment of colic
Temporal association with feeds
Variation in context and environmental factors
Parental response
Supports for the parents
Research definition
> 3 hours crying/day for >3 weeks
Common non-pathalogical causes of crying
+Tiredness
Hunger
Temperature
Average sleep requirements at birth, 2-3 months
At birth 16 hours
2-3 months 15 hours/day
How long after being awake does a 6 week and 3 month old baby become tired
At 6 weeks->1.5 hours
At 3 months->2 hours
When is hunger a more likely cause of colic
Baby has frequent feeds
When to suspect cow milk/soy milk protein allergy
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)
How is the diagnosis of cows milk allergy made and what is done
Clinical
Eliminate cow milk->modify mothers diet/changing to extensively hydrolysed formula
Can cow milk/soy milk protein be in breast milk
Yes
Is goats milk allergic
Yes, as allergenic as cows milk
Is silent reflux (reflux without vomiting) a likely cause of an infant crying
No
Does the amount of crying reflect the severity of the GORD
No
Role of medication in GOR
Ranitidine and omeprazole have not been shown to be effective in reducing crying
In the absence of frequent vomiting, anti-reflux medication to manage persistent infant irritability is not recommended
When to suspect lactose intolerance/malabsorption
Frothy watery diarrhea
Perianal excoriation
How is diagnosis of lactose intolerance made
presence of faecal reducing substances ≥0.5%% and pH
Differential for lactose intolerance in formula fed and breast fed
in breastfed babies, may be functional lactose overload (high lactose content in breast milk in babies who frequently switch breastfeeding sides +/- feed frequently ie
Management of lactose intolerance for formula feb and breastfed
Formula: lactose free/hydrolysed formula
Breastfed: space feeds >3 hours, empty breast at each feed and alternate sides for feeding. Consider referral to lactation consultant for feeding advice
If crying is acute onset, differential
If crying is of acute onset, consider:
Urinary tract infection Otitis media Raised intracranial pressure Hair tourniquet of fingers / toes Corneal foreign body / abrasion Incarcerated inguinal hernia
Red flags (3)
Red flags:
- Sudden onset of irritability and crying should not be diagnosed as colic; a specific cause is usually present
- The maternal and family psychosocial state must be taken into account. Maternal post-natal depression may be a factor in presentation. Note that excessive crying is the most proximal risk factor for Shaken Baby Syndrome.
- Suspect cow milk / soy protein allergy if
- vomiting / blood or mucus in diarrhoea / poor weight gain / family history in first degree relative / signs of atopy (eczema / wheezing) / significant feeding problems (especially worsening with time)
- gastro-oesophageal reflux is diagnosed
- lactose malabsorption is diagnosed in formula-fed babies
Algorithm for acute management: H&E, if no?, if yes?
History and examination:
- Vomiting, diarrhea
- Eczema
- Failure to thrive
- Feeding difficulties
Yes:
-Consider cows milk allergy, GORD–>consider trial of cow milk free formula/maternal diet
No:
- Medical cause unlikely–>baby tired? Hungry? Unable to self soothe?
- Colic management: discuss normal sleep and crying, settling techniques, parental support, arrange regular follow up
Investigations in colic
Generally not required
May consider stool examination for reducing substances and pH
Urine MCS for acute crying and vomiting
Fluroscein staining if history suggestive
Assisting parents to calm their baby (10)
- Establish pattern to feeding / settling / sleep
- Aim to settle the baby for daytime naps and night-time sleep in a predictable way (eg, quiet play, move to the bedroom, wrap the baby, give the baby a brief cuddle, then settle in the cot while still awake)
- Avoid excessive stimulation - noise, light, handling.
- Excessive quiet should also be avoided. Most babies find a low level of background noise soothing
- Darken the bedroom for daytime sleeps
- Carry baby in a papoose in front of the chest
- Baby massage / rocking / patting
- Gentle music
- Respond before baby is too worked up
- Give the mother permission to rest once a day without the need to carry out household chores. Have somebody else care for the baby for brief periods to give the parents a break.
Medications and treatment options for colic
- Medication is rarely indicated.
- Colic mixtures, gripe water etc are of no proven benefit.
- Anticholinergic medications are not recommended due to the risk of serious adverse events (apnoeas, seizures).
- Simethicone (Infacol Wind Drops / Degas Infant Drops) has no effect on infant crying when compared with placebo
- Spinal manipulation= placebo
- Formula changes are generally not helpful unless proven cow milk protein allergy
When to consider consulting with pediatrician
Cause unknown, appears unwell
Follow up
Referral within days for ongoing support is vital Options: -Maternal/CH nurse -Local medical officer -GP -Unsettled baby clinic -Mother-baby day unit -Admission to hospital->if child considered at risk of non-accidental injury or parental exhaustion
Follow up advice to parents
See a doctor if:
You need reassurance that there is no medical cause for the crying.
Your baby is refusing feeds or is having less than half their normal feeds.
Your baby does not seem to settle with any of the things you are trying.
Your baby continues to cry for long periods.
You feel you are not coping.
You feel the crying is impacting on your relationship with your baby.
You are finding it hard to enjoy your baby or to feel positive about them.
You feel your mental health or your relationship with your partner is being affected.
OR you are worried for any other reason.
Cry baby checklist (10)
- Comfort
- Hungry
- Dirty nappy, rash
- Burp
- Uncomfortable
- Suck
- Overtired
- Conditions right to settle
- Sick, fever
- Does parent need a break
Red flags not associated with infantile colic, suggesting more serious condition
Fever Lethargy Poor feeding Less responsive socially Poor weight gain
Clinical assessment critical points in history, examination
Always ask about feeding, temperature, change in behaviour or social
responsiveness.
Are there any other symptoms to suggest serious disease e.g. vomiting, lethargy,
poor weight gain?
Never forget to examine the groin for testicular torsion or incarcerated inguinal
hernia.
If irritability is associated with a temperature, manage as “Febrile Infant”.
One month old Tim- mother concerned as more irritable:
History
Feeding Weight changes Vomiting, diarrhea Fever Temporal relationship What he does during the episode How he is between crying Mothers reactions, supports, mood
One month old Tim- mother concerned as more irritable: examination
Temperature
Weight gain
General observations->social interaction
Abdominal exam->ALWAYS check for incarcerated hernia
What to tell Tim’s mother
This a well-recognised but poorly understood condition that spontaneously resolves by 3 months of age.
No long term complications
Mother may need help from friends/family
Avoid overfeeding, wind regularly, rick/carrying can help
No drugs have been shown to be safe, or help
John is an 8 month-old boy who 4 hours ago suddenly started crying, could not be
consoled, looked pale and grey and vomited 10 times. His irritability lasted for about 1
hour. John’s mother’s friend suggested that
this was infantile colic.
Wrong age
Sudden onset
Colour change and vomiting->suggestive of serious acute disorder
Intussusception
Strangulated inguinal hernia
Testicular torsion
Malrotation
