Pediatric Annals

Special Issue Article 

Emergency Department Triage of the “Incessantly Crying” Baby

Caroline Chua, MD; Jennifer Setlik, MD; Victoria Niklas, MD

Abstract

This article has been amended to include factual corrections. To read the erratum, click here. The online article and its erratum are considered the version of record.

Incessant crying is one of the most common caregiver complaints during emergency department (ED) visits in the first few months of the child's life. Although the majority of cases are attributed to normal infant behavior, the differential diagnosis remains broad. Moreover, the potential for the negative impact of incessant crying on the mental well-being of caregivers as well as the infants necessitates that complaints be taken seriously and that “red flags” for underlying organic causes be ruled out and caregiver anxiety quelled. In addition, the apparent triviality of incessant crying in the face of the life-threatening illnesses or injuries that confront practitioners in the ED necessitates a high level of due diligence in the evaluation of these infants and their families. Ensuring the availability of family support is essential in the discharge planning. Families should also perceive the empathy of the physician and feel reassured about their safe discharge home. Although it is a challenge to examine an incessantly crying infant in all care settings, the failure to recognize the small percentage of infants that present with incessant crying as a manifestation of an underlying organic illness may have grave consequences. [Pediatr Ann. 2016;45(11):e394–e398.]

Abstract

This article has been amended to include factual corrections. To read the erratum, click here. The online article and its erratum are considered the version of record.

Incessant crying is one of the most common caregiver complaints during emergency department (ED) visits in the first few months of the child's life. Although the majority of cases are attributed to normal infant behavior, the differential diagnosis remains broad. Moreover, the potential for the negative impact of incessant crying on the mental well-being of caregivers as well as the infants necessitates that complaints be taken seriously and that “red flags” for underlying organic causes be ruled out and caregiver anxiety quelled. In addition, the apparent triviality of incessant crying in the face of the life-threatening illnesses or injuries that confront practitioners in the ED necessitates a high level of due diligence in the evaluation of these infants and their families. Ensuring the availability of family support is essential in the discharge planning. Families should also perceive the empathy of the physician and feel reassured about their safe discharge home. Although it is a challenge to examine an incessantly crying infant in all care settings, the failure to recognize the small percentage of infants that present with incessant crying as a manifestation of an underlying organic illness may have grave consequences. [Pediatr Ann. 2016;45(11):e394–e398.]

Incessant crying is reported by approximately 20% of caregivers1 and is one of the most common complaints during emergency department (ED) visits in the first few months of a child's life. Crying episodes may be triggered by the interplay of cultural, psychological, environmental, and biological factors in a normal newborn, whereas organic disorders likely account for only 5% to 10% of the cases.2 Regardless of the etiology, when crying is perceived as excessive, caregiver or parental distress may result and lead to family instability, psychological disturbance, and even child abuse.3 Up to 6% of parents retrospectively report engaging in physically abusive behaviors toward their baby when he or she cried.4 Although crying is a normal mode of infant communication, often signifying unmet needs such as hunger, physical discomfort, anger, or frustration, incessant crying may have substantial negative health consequences for the caregiver and the infant. Despite its prevalence, no consensus has been reached on the definition of “incessant crying,” although the “rule of three” has been widely used.5 The “rule of three” defines incessant crying or fussing as crying for more than 3 hours a day, occurring on more than 3 days in any week, and for at least 3 weeks.6 The average length of crying in normal infants in the United States is approximately 3 hours per day at age 6 weeks, often decreasing until age 16 weeks (4 months).7 Many infants may cry less than this, but are still perceived by their caregivers or parents to have abnormally long periods of crying. There are many reasons, other than “colic,” that may cause an infant to cry incessantly. These range from simple problems such as hunger or thirst to more serious medical conditions such as sepsis.

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


            “Red Flags” for Identifying Organic Causes of Incessant Crying

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.


            Common Organic Causes of Incessant Crying

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).


            Aspects of Patient History

Table 3.

Aspects of Patient History

Physical Examination

The physical examination begins with careful observation of the caregivers' interaction with the infant while quiet and with paroxysms of crying. This can help determine whether the infant is active, alert, or ill-appearing. A severely ill infant may appear lethargic and exhibit cardiorespiratory symptoms interspersed with episodes of crying. An otherwise well-appearing infant will usually be well-appearing between episodes of crying. This observation may also reveal caregiver mechanisms for coping and ability to soothe the infant during crying spells. Vital signs in the infant should be taken, including blood pressure, pulse oximetry, and weight. All infant clothing should be removed and a systematic examination from head to toe performed. Skin should be inspected for color (pallor or jaundice), and evidence of trauma from constriction injuries (including hair tourniquets) or burns where mittens and stockings cover the skin should be noted. Large bones should be palpated for possible fracture, which may indicate the nonaccidental trauma of child abuse. The clavicles should be examined for tenderness, crepitation, or deformity indicative of physical injury.

Weight gain since birth should be assessed. Poor weight gain may signify underlying organic diseases or be a sign of feeding disorders, gastroesophageal reflux, or poor caregiver (maternal) bonding. Any changes in mental status during the examination, such as a fluctuating level of alertness or lethargy, may suggest organic illness. Full fontanels may indicate meningitis, hypoglycemia, head trauma, or the presence of a space-occupying lesion. An infant with excessive tearing or injected conjunctivae may suggest conjunctivitis, foreign body, or corneal abrasion. Ears, nose, and oropharynx should be carefully visualized for the presence of ear infection, foreign body, or oral thrush. Difficulty breathing with wheezing or crackles may point to cardiac or pulmonary disease. The presence of cardiac murmur with poor perfusion is indicative of heart disease unless proven otherwise. Infants with intra-abdominal catastrophes may present with obvious signs of peritonitis and hemodynamic instability. The diaper region should be inspected for anal fissures, and the perineal area inspected for signs of trauma in both boys and girls, which could be indicative of sexual abuse. The testes should be inspected and palpated to determine whether the testes are normally descended. The presence of testicular redness, pain, or mass may be indicative of testicular torsion. A mass in the inguinal canal, labia, or scrotum may indicate intestinal or ovarian hernia.

Laboratory Tests and Imaging

Diagnostic laboratory and radiographic studies to identify the etiology of incessant crying are of limited value when used as screening tests. In a cohort study where history and physical findings were inconclusive, the diagnostic studies were helpful in only 3% of the cases.2 However, when diagnostic studies are used as confirmatory tests, such as performing a chest radiograph for suspected pneumonia, abdominal ultrasound to confirm intussusception, and upper gastrointestinal series to confirm suspected intestinal malrotation, the value increased to more than 10%.2

In another study, when the diagnosis remained obscure after a thorough history and examination were performed, screening tests were limited to urinalysis and urine culture with a period of observation or follow-up.10 This may be all that is needed to assist the providers in their assessment, especially if the infant is gaining weight normally with normal physical examination.

Making a Diagnostic Decision

A thorough clinical assessment should guide decision-making about further investigations. If there are no clues in the patient's history or physical examination suggesting a specific infection or area of suspicion, it is unlikely that diagnostic studies will be helpful in identifying the etiology. A period of observation or close follow-up at home or with the primary care physician may be all that is needed. Continued observation may provide additional clues to assist providers in their selection of further diagnostic testing until a diagnosis is made. Although it is a challenge to examine an incessantly crying infant in all settings, missing the small percentage of underlying serious illnesses may have grave consequences. At times, negative results help in ruling out serious illness and provide reassurance to both the caregivers and health care providers.

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).


            Emergency Department Triage for Crying Infants

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.

References

  1. Wake M, Morton-Allen E, Poulakis Z, Hiscock H, Gallagher S, Oberklaid F. Prevalence, stability, and outcomes of cry-fuss and sleep problems in the first 2 years of life: prospective community-based study. Pediatrics. 2006;117(3):836–842. doi:10.1542/peds.2005-0775 [CrossRef]
  2. Freedman SB, Al-Harthy N, Thull-Freedman J. The crying infant: diagnostic testing and frequency of serious underlying disease. Pediatrics. 2009;123(3):841–848. doi:10.1542/peds.2008-0113 [CrossRef]
  3. McMahon C, Barnett B, Kowalenko N, Tennant C, Don N. Postnatal depression, anxiety and unsettled infant behaviour. Aust N Z J Psychiatry. 2001;35(5):581–588. doi:10.1080/0004867010060505 [CrossRef]
  4. Vik T, Grote V, Escribano J, et al. Infantile colic, prolonged crying and maternal postnatal depression. Acta Paediatr. 2009;98(8):1344–1348. doi:10.1111/j.1651-2227.2009.01317.x [CrossRef]
  5. Reijneveld SA, Brugman E, Hirasing RA. Excessive infant crying: the impact of varying definitions. Pediatrics. 2001;108(4):893–897. doi:10.1542/peds.108.4.893 [CrossRef]
  6. Wessel MA, Cobb JC, Jackson EB, Harris GS Jr, Detwiler AC. Paroxysmal fussing in infancy, sometimes called colic. Pediatrics. 1954;14(5):421–435.
  7. Brazelton TB. Crying in infancy. Pediatrics. 1962;29:579–588.
  8. Gormally S. Clinical clues to organic etiologies in infants with colic. In Barr R, St. James-Roberts I, Keefe M, eds. New Evidence on Unexplained Early Infant Crying: Its Origins, Nature and Management. Skillman, NJ: Johnson and Johnson Pediatric Institute; 2001:133–148.
  9. Allister L, Ruest S. A systematic approach to the evaluation of acute unexplained crying in infants in the emergency department. Pediatr Emerg Med Pract. 2014;11(3):1–20.
  10. Poole SR. The infant with acute, unexplained, excessive crying. Pediatrics. 1991;88(3):450–455.
  11. Barr RG. Colic and crying syndromes in infants. Pediatrics. 1998;102(5 Suppl E):1282–1286.
  12. Poole SR. Corneal abrasion in infants. Pediatr Emerg Care. 1995;11(1):25–26. doi:10.1097/00006565-199502000-00007 [CrossRef]
  13. Roberts KBSubcommittee on Urinary Tract InfectionSteering Committee on Quality Improvement and Management. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128(3):595–610. doi:10.1542/peds.2011-1330 [CrossRef]
  14. Roberts DM, Ostapchuk M, O'Brien JG. Infantile colic. Am Fam Physician. 2004;70(4):735–740.
  15. Fox S. Inconsolable infant. http://pedemmorsels.com/?s=%22inconsolable+infant%22. Accessed October 17, 2016.
  16. Herman MI, Le A. The crying infant. Emerg Med Clin North Am. 2007;25(4):1137–1159.

“Red Flags” for Identifying Organic Causes of Incessant Crying

<list-item>

Extreme, prolonged, and high-pitch cry

</list-item><list-item>

Lack of diurnal pattern

</list-item><list-item>

Incessant crying beyond age 4 months

</list-item><list-item>

Presence of frequent regurgitation, vomiting, diarrhea, weight loss, and/or failure to thrive

</list-item><list-item>

Family history of migraine, asthma, and atopy

</list-item><list-item>

Maternal drug ingestion or history of illicit substance abuse

</list-item><list-item>

Abnormal vital sign or physical examination findings

</list-item>

Common Organic Causes of Incessant Crying

<list-item>

I = Infection (AOM meningitis UTI pneumonia sepsis)

</list-item><list-item>

T = Trauma (nonaccidental trauma SDH fractures shaken baby syndrome CNS tumor)

</list-item><list-item>

C = Cardiac disease (SVT CHD)

</list-item><list-item>

R = Reaction to bites and medications GERD rectal/anal fissures

</list-item><list-item>

I = Immunization intussusception incarcerated hernia inborn error of metabolism

</list-item><list-item>

E = Eyes (corneal abrasion foreign body retinal hemorrhage/detachment glaucoma) electrolytes imbalance

</list-item><list-item>

S = Strangulation surgical process (volvulus testicular/ovarian torsion)

</list-item>

Aspects of Patient History

History Clinical Observations
Illness Onset, duration, frequency, and time of crying episodes Attempted interventions and outcomes Associated activities/behaviors History of similar episodes and any prior evaluations
Birth Prenatal and birth history Pregnancy and/or perinatal complications Prenatal screening results Substance use during pregnancy
Feeding/intake Breast-feeding frequency, difficulties, maternal medications, supplements, and diet Formula feeding, type of formula, and method of preparation Temporal relationship between crying and feeds Any unusual signs/symptoms during feeds
Voiding/stool Normal voiding/stool patterns History of urinary tract infection or known anatomic abnormality History of laxative, enema, or stool softener use
Past medical History of prior illnesses/hospitalization Developmental milestones, growth, and weight gain Recurrent or recent medications Immunization status
Family Congenital, metabolic, genetic disorders
Social Home environment (stress, domestic violence, social services involvement) Caregivers Exposure to tobacco, alcohol, or drugs in the home

Emergency Department Triage for Crying Infants

Criteria for Admission Criteria for Discharge
Toxic-appearing Hemodynamically unstable Critical illness Clinically stable with need for intravenous treatments No access to follow-up care Ongoing crying without a clear-cut etiology after examination and observation Social concerns Well-appearing Clinically stable with condition treated as outpatient Accessto immediate follow-up care Resolution of crying in the emergency departmentor ongoing crying that is baseline No social concerns Parents comfortable with discharge plan and understand the next steps
Authors

Caroline Chua, MD, is a Neonatologist, Division of Neonatal Medicine, Department of Pediatrics, Nemours Children's Hospital; and an Assistant Professor, University of Central Florida College of Medicine. Jennifer Setlik, MD, is a Pediatric Emergency Medicine Physician, Division of Emergency Medicine, Department of Pediatrics, Nemours Children's Hospital; and an Assistant Professor, University of Central Florida College of Medicine. Victoria Niklas, MD, is a Neonatologist, Division of Neonatology and Newborn Services, Olive View-UCLA Medical Center; and a Professor of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles.

Address correspondence to Caroline Chua, MD, Division of Neonatal Medicine, Department of Pediatrics, Nemours Children's Hospital, 13535 Nemours Parkway, Orlando, FL 32827; email: caroline.chua@nemours.org.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/19382359-20161017-01

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