Emergency Department Triage of the “Incessantly Crying” Baby

Common Causes of Incessant Crying or Fussiness

There are several reasons that an infant may cry incessantly, ranging from hunger, fatigue, or overstimulation to more serious conditions such as infections. Gormally⁸ identified certain “red flags” that may suggest an underlying organic etiology (Table 1). Physical examination from head to toe, including the skin, eyes, and large bones, and thorough neurological, cardiovascular, and gastrointestinal assessments are also important.⁹

Table 1. “Red Flags” for Identifying Organic Causes of Incessant Crying

Although the differential diagnosis of incessant crying is extensive and involves every organ system, organic causes account for less than 10% of cases.^10,11 Organic causes can be remembered by using the acronym “IT CRIES” (Table 2). An underlying infectious cause should be considered, such as acute otitis media, meningitis, urinary tract infection (UTI), viral or bacterial pneumonia, or sepsis. In one cohort study, UTI was the most common serious diagnosis, accounting for 25% of all serious etiologies.² Incessant crying may be a precipitating factor or a result of physical trauma caused by child abuse. Indeed, in an infant with subdural hematoma and fracture to large bones (“shaken baby syndrome”), child abuse must be considered.

Table 2. Common Organic Causes of Incessant Crying

A history of apnea, cyanosis, or “struggling to breathe” may suggest previously undiagnosed pulmonary or cardiac conditions. Reaction to medications and vaccines are not difficult to diagnose because they present with history of drug intake or recent vaccination. More difficult to diagnose are subtle gastrointestinal disorders such as gastroesophageal reflux disease, intussusception, volvulus, and incarcerated hernia, as they are all likely to present with subtle and nonspecific findings. Although an eye examination is not given much attention by most physicians, ocular foreign body and corneal abrasions should be ruled out in some infants presenting with incessant crying. In one study by Poole,¹² nearly 5% of infants with a history of ocular trauma had positive fluorescein staining tests, implying that in some cases it may account for incessant crying. A retinal examination is paramount in the evaluation of an infant suspected of injury through child abuse. Infants presenting with bilious emesis, poor feeding, and abdominal distention may have surgical emergencies such as intestinal malrotation complicated by volvulus or other intestinal obstruction.

Challenges in Establishing the Diagnosis

A thorough history and physical examination are the cornerstones in the diagnosis of an infant with incessant crying. This approach is diagnostic in 20% to 86% of cases, either alone or in conjunction with physical examination findings.^2,10

Patient History

The physician should obtain a detailed history from the primary caregiver or parent, tailored to the age of the infant. The onset, duration, frequency, aggravating and alleviating factors of the crying, and associated activities such as feeding and sleeping disturbances should be investigated. Birth history, past medical history, and family history may guide diagnosis. If the infant is breast-feeding, specific inquiry about maternal prescription drug use, illicit drug use, alcohol intake, and cigarette smoking is important. Asking about stool frequency and consistency may lead to organic etiologies. A history of constipation with frequent use of laxatives may indicate Hirschsprung's disease. Presentation of bloody stool may indicate an anal fissure, milk protein allergy, or a more serious condition such as intussusception or Meckel's diverticulum. Documentation of frequency, quantity, and character of spitting up is necessary to rule out gastroesophageal reflux or pyloric stenosis. A thorough social history and assessment is important. Determining the level of family support and stability, the presence of maternal fatigue, anxiety, and depression, or a history of substance abuse may illuminate difficulties with maternal infant bonding. As parents and caregivers may not volunteer information unless specifically asked, the involvement of state social and family services is crucial when the organic causes are ruled out (Table 3).

Table 3. Aspects of Patient History

Challenges in Management

The initial management of the infant with incessant crying begins with a comprehensive history and physical examination, as it would for any infant presenting to the ED. A clinically unstable patient should be stabilized before continuing the evaluation. This would include cardiorespiratory monitoring, intravenous access and fluid if indicated, and bedside glucose screening. If the vital signs are stable but there is presence of a fever, then the American Academy of Pediatrics practice guidelines for febrile infants are a reliable management strategy and approach.¹³ An easily consoled infant that stops crying spontaneously may be observed with serial examinations. However, if one is unable to determine an underlying cause, ancillary testing may be considered. Although laboratory testing and other testing are not routinely indicated, a urinalysis has been shown to be the most useful test in making a diagnosis.²

The testing in the ED should be individualized to each patient, although with the understanding that most crying infants do not have serious underlying organic illnesses. Given the fear of “missing something,” ED practitioners may tend toward overevaluation. There are no evidence-based clinical algorithms or practice guidelines to support this practice.⁹ Additionally, there are no recommendations for routine use of radiographic imaging of any kind. The disposition, however, is not dependent on establishing a diagnosis as to why the infant has been crying, but that organic illnesses have, in all likelihood, been ruled out. If the initial history and physical examination are not revealing, a period of observation in the ED may be useful. This may allow other features of organic illness to manifest, such as fever, signs of abdominal pathology, or caregiver maladaption. There is no defined time requirement for observation, but when concerning features in the physical examination remain after a period of observation (such as disinterest in feeding), then the infant should be admitted for inpatient observation (Table 4).

Table 4. Emergency Department Triage for Crying Infants

The evaluation and treatment of a crying infant in the ED falls into two categories: those with recognizable and treatable illness, and those who continue to cry without a clear identifiable cause. There are clear directions for those who have recognizable illness and those who meet criteria for admission. For those who meet outpatient treatment or discharge criteria, the disposition can be more challenging. Outpatient follow-up within 24 hours is important, as this gives both clinicians and caregivers a definitive next step in the evaluation. Although caregivers may request medications, this is never indicated when the target is unknown or unclear, as treatment may mitigate symptoms and adversely delay proper diagnosis and definitive treatment. Treatments generally not recommended include changing of formula (except in cases of proven cow's milk allergy), cessation of breast-feeding (unless substance abuse is confirmed), and use of simethicone.¹⁴ Sometimes, after a period of observation the only treatment for the family is reassurance and a discussion that organic pathologies have been ruled out. For a caregiver in whom reassurance is not effective, additional observation or evaluation by social and family services evaluation is required and may be beneficial.

Clinicians should discuss the supportive measures families can provide at home for the basic needs of their infant, such as regular and full feedings to ensure satiety, diaper care and avoiding discomfort from soiled diapers, attendance to temperature regulation, and assuring regularity and uniformity to daily care. Discharge plans should include clear reasons to return to the ED or primary care providers. Reasons to return for evaluation should include inconsolability, inability to eat, excessive sleepiness, inability of the caregiver to contend with the stress and feelings of being overwhelmed, or any new or concerning symptoms that appear.

Conclusions

Incessant crying in the first few months of life is usually benign and self-limiting, although in a minority of cases it is linked to underlying organic illness. A thorough prenatal, perinatal, and birth history, including thorough physical examination, will resolve most cases. No routine investigations are needed for an afebrile infant without evidence of systemic signs or symptoms. A thorough psychosocial assessment is crucial, as an unstable home environment may put the infant at risk for child abuse and neglect. Family education regarding the natural history and pattern of crying in infants should be given so that caregivers can have a realistic view of what to expect and are reassured that an underlying organic illness is unlikely.