Upon completion of this self-study module, you should be able to:

• Describe how to develop an initial impression for an infant presenting to the emergency department with excessive crying
• List the critical diagnoses for excessive crying
• Discuss the utility of laboratory tests and radiological imaging in evaluating excessive crying
• Discuss appropriate management for the critical diagnoses associated with excessive crying
  

Initial Actions and Primary Survey

Evaluating and managing an infant with the nonspecific complaint of excessive crying is challenging. Crying is an infant’s primary means to communicate physiologic needs (e.g. hunger) or discomfort. Infant crying typically peaks around the 6th week of life (mean duration 110-118 minutes per day) and decreases to just over an hour per day by the 12th week of life.1

Unfortunately, there is no consensus as to what constitutes excessive crying. Infant colic has been described by the “rule of 3”: crying that lasts > 3 hours per day, for > 3 days per week in an otherwise healthy infant between 3 weeks and 3 months of life.2 However, it is important to note that infant colic is a diagnosis of exclusion, and the acute presentation of excessive crying may indicate significant pathology. Though the data is limited, in one study of infants with acute, excessive crying, 61% had a serious etiology identified. 3 Considering the vague description of excessive crying, and the potential for a serious underlying etiology, a careful evaluation should be pursued in any infant with a crying pattern deemed abnormal for developmental age, or excessive from the parent’s perspective.

What initial actions should be taken in an infant with excessive crying?

• Develop an initial impression
• Perform a primary assessment
• Conduct a secondary assessment consisting of a thorough history and physical examination focused on the presenting complaint
• Order appropriate laboratory and imaging studies as indicated
• Initiate therapeutic interventions directed towards correcting physiological abnormalities and treating  the suspected underlying etiology
  

Initial Impression

The emergency assessment of any child or infant starts with the initial impression. This initial impression is an observational assessment or “first look impression” based on the visual and auditory presentation of the patient when first encountered, and it precedes the ABCDEs of the primary assessment. The Pediatric Assessment Triangle (PAT) is a tool designed to provide health care professionals a standardized means to generate the initial impression of an ill infant or child.4 It is composed of 3 components: work of breathing, circulation to the skin, and appearance. Characteristics of each PAT component allow a health care professional to quickly assess if the component is normal or abnormal (see table below). Once each component is assessed, combination of the 3 provides a picture, or initial impression, of the patient’s cardiopulmonary and central nervous system status. The initial impression is not designed to provide a diagnosis, rather it identifies the general category of physiologic derangement and severity.

Derived from: Dieckman RA, Brownstein D, Gausche-Hill M. The Pediatric Assessment Triangle: A Novel Approach for the Rapid Evaluation of Children. Pediatric Emergency Care 2010: 26; 312-315.

Primary Assessment

The primary assessment is a structured physical assessment that proceeds in a specific order (see table below).

---

Secondary Assessment

The secondary assessment consists of a thorough history and physical examination focused on the presenting complaint. It should be performed only after the initial impression and primary assessment are completed and the patient is stabilized. Any life or limb threatening emergencies should be identified and addressed prior to initiating the secondary assessment.

The secondary assessment is performed to:

• Delineate circumstances of the current condition (e.g. How long has the infant been crying? Does anything help diminish/stop the crying? What makes the crying worse?)
• Identify physical signs that are not readily apparent or subtle (e.g. hair tourniquet of the digit, corneal abrasion, or otitis media)
• Create a differential diagnosis that drives diagnostic testing and subsequent management (e.g. suspicion for meningitis should prompt a lumbar puncture, cerebrospinal fluid analysis, and early antibiotic administration)

A careful secondary assessment may provide all the clues necessary to identify the cause of excessive crying in an infant or small child.

Diagnostic Laboratory and Imaging Studies

Laboratory studies and radiological imaging of an infant with excessive crying are driven by the differential diagnosis. There is no set diagnostic evaluation for an infant with excessive crying, rather it is specific to the suspected diagnosis. For example, if concerned for pyloric stenosis or intussusception, an abdominal ultrasound is the appropriate imaging study. If concerned for sepsis, a complete blood count, blood culture, electrolytes, blood glucose, urinalysis and culture, and cerebrospinal fluid analysis with culture may be indicated.

Initial Therapeutic Interventions

Therapeutic interventions in the excessively crying infant are prompted by physiologic abnormalities, physical examination abnormalities, and suspected underlying causes. For example, suspicion for meningitis mandates early, broad-spectrum, intravenous antibiotics.

Differential Diagnosis

The differential diagnosis for excessive crying in an infant is broad and the spectrum of potential problems ranges from relatively benign entities (infant colic, oral thrush) to serious and life threatening conditions (malrotation with volvulus, bacterial meningitis, sepsis).

---

References

1. Dieckman RA, Brownstein D, Gausche-Hill M. The Pediatric Assessment Triangle: A Novel Approach for the Rapid Evaluation of Children. Pediatric Emergency Care 2010: 26; 312-315.
2. Poole SR. The infant with acute, unexplained, excessive crying. Pediatrics 1991: 88; 450-455.
3. Wessel MA, Cobb JC, Jackson EB, et al. Paroxysmal fussing in infancy, sometimes called colic. Pediatrics 1954: 14; 421-424.
4. Wolke D. Samara M. Alvarez-Wolke M. Meta-analysis of fuss/cry durations and colic prevalence across countries. Proceedings of the 11th International Infant Cry Research Workshop. June 2011, The Netherlands.