3. Most common complaint , for which the child is
brought to Pediatrician/ Primary Physician
Lot many reasons why child cry ! Prevalence of
excessive crying 1.5 – 40 %
UK study annual cost of 108 million dollars spent
by NHS on care of infants with crying & difficulty
in sleeping in 1st 12 wks alone
4. We have to differentiate when the cry is an
abnormal & find out the reason behind it
Each case should be looked as a clinical
challenge rather than as annoyance
Fear of missing a diagnosis may result in
unnecessary & invasive tests
5. Crying is an important cause of maternal
anxiety & stress, strongly associated with
maternal depression.
Can affect breast feeding
Stress in relationships – mother-infant ,
mother- family members , mother – father
relationship
Can be associated rarely with physical
violence
6. Brazelton ( 1962)-studied babies from birth -
12wks
Infants in their 2nd wk of life cried & fussed for
median 1.75 hrs, which increased to a peak
median of 2.75 hrs at 6 wks, after which there
was decline in the amount of crying
There appears circadian pattern , concentrated
most in late afternoon and evening.
7. Illingworth (1954 )- described 50 infants <
3months with’ rhythmic attacks of screaming’
,without any inciting cause & labeled them as
“Three months colic”
Wessel et al used the term “ paroxysmal
fussing “ .
Amount of crying that is considered excessive
is accepted fromWessel’s studies (>3 hrs)
8. (1) to avoid missing a serious or life-
threatening aetiology
&
(2) to determine the common/treatable
diagnoses .
In their study of 200 crying infants who
presented to the ED, Fahimi et al found that the
3 most common diagnoses were colic (29.5%),
acute otitis media (15.5%), and constipation
(5.5%)
9. Hunger, thirst, tiredness ,discomfort
Separation from mother
Temperature disturbances in the
environment
Need to clean up
10. Most of the diseases of neonates, infants and
children have irritability as a major
manifestation.
For pediatrician it is important to decide the
cause of irritability/crying, though difficult
at times
11. Complaint of crying is so nonspecific,
differential diagnosis is so extensive,
THOROUGH HISTORY , CLINICAL
EXAMINATION
TOP UPWITH
YOUR CLINICAL EXPERIENCE !!!
12. parental concern was “red flag” in identifying
serious illness, with a positive likelihood ratio (LR) of
14.4 (95% confidence interval [CI] 9.3-22.1 (Van den
Bruel et al )
Clinician’s concern : “gut feeling” that something was
wrong, despite the assessment, substantially
increased the likelihood of serious illness with a LR of
25.5 (95% CI, 7.9-82)
history as diagnostic in 20% to 86% of cases, alone
or in conjunction with physical examination
findings
13. Poole et al- emergency department visits
with ages ranging 4 days- 24 months-
61 % had diagnosis that was serious illness, of
those history provided clues in 20 %
physical examination provided Dx in 41%
& clues leading to Dx in 13%, remaining 24%
continued to cry after initial assessment
14. Examine patient from head to toe literally !!
General examination: temperature, pulse,
respiration ( vitals ), hydration of the baby
Examination of head: anterior fontanel
(boggy/ depressed )
prominent veins over scalp
sutural separation
15. Ears : otoscopy ( AOM/ MEE)
discharge from ears
foreign body
Nose : sinusitis
bloody discharge ( foreign body )
Throat : vesicles (herpangina )
pooling of secretions ( parapharyngeal
abscess)
21. Respiratory system : tachypnea , crepts/
bronchial breathing , e/o foreign body
Per Abdomen : mass / lump in abdomen
(intusseption ) , P/R exam if required
Don’t forget to undress the child -- impacted
inguinal hernia, torsion of testis may be
missed
24. Examine all bones and joints carefully to
exclude fractures
joints for e/o septic arthritis , transient
synovitis
look for pseudo -paralysis as in Scurvy
26. CNS : most important to r/o Intracranial
infection
Examine for toxicity, see neuro behavior of
the child, feeding history ,convulsions, focal
neurological signs.
Genitourinary system : dysuria,
perivulval/perianal redness , labial synaechiae
27.
28.
29. Head & eyes :
1. trauma
2. corneal abrasion
3. ocular/nasal/ear foreign body
4. glaucoma
5. panniculitis
30. Respiratory system :
UR system – blocked nose
acute otitis media
foreign bodies
LR system – bronchiolitis
pneumonia
foreign bodies
pneumothorax
37. Miscellaneous causes :
drug overdoses ( nalidixic acid,VitaminA etc)
post vaccination ( DPwT)
recovery from neurological diseases
Scurvy
38. 1) Infants with clear diagnosis/ identifiable
cause
(2) infants who continue to cry without a clear,
identifiable cause
---outpatient follow up visit within 24 hours
----avoidance of medicating unknown / unclear
diagnosis
--- reassurance and supportive measures to the
parents
39. Consider common diagnosis first
Rule out serious underlying disorders
Colic has historically been defined as paroxysms of
excessive crying lasting > 3 hours per day, occurring
> 3 days in any week for 3 weeks, in an otherwise
healthy baby aged 2 weeks to 4 months. It is
estimated to affect 10% to 30% of infants
worldwide.
40. Proposed causes include:
cow’s milk protein allergy or intolerance,
gastrointestinal reflux disease,
feeding difficulties, sleep difficulties,
and neurodevelopmental immaturity
Baby parent interaction
41. Don’t initiate extensive & expensive work up on
every crying patient
May not be possible to identify the correct etiology
during Emergency visit , can arrange follow up visit
Don’t forget urine analysis
42. For Crying Infants
Criteria For Admission
Toxic-appearing
Hemodynamically unstable , critical illness
Clinically stable with a condition requiring IV
therapy (fluids, antibiotics)
No access to immediate follow-up care
Ongoing crying without a clear-cut etiology
after examination, observation, and
appropriate testing
Social concerns (poor support at home,
unsafe environment for the infant, risk
factors for abuse or neglect)
43. 1.Well-appearing/consoled
Clinically stable with a condition
treatable in outpatient therapy (oral
antibiotics, analgesics)
2.Access to immediate follow-up care
Resolution of crying in the ED or
ongoing crying that is baseline or not
concerning to provider or caregiver
3.No social concerns
Parents are comfortable with discharge
plan and understand next steps
regarding treatment and follow-up
44. “The baby did not have a fever, so I did not
consider that he could have a serious
infection
“Of course the baby had an elevated heart
rate; he was crying
The parents seem really nice, so there is no
need to consider nonaccidental trauma.”
45. “All babies cry.This is a normal finding and is
nothing to worry about.” ( thik ho jayega)
“The more tests I perform, the closer I will be to
making a diagnosis
“This baby just has colic”
“Parents are always anxious about their babies,
but it doesn’t mean anything is truly wrong
with the infant.”
46. History and clinical examination …the most
important tools
No universally recommended lab tests/ imaging
studies….. Individualize the decisions
Colic & unexplained crying are the most
common, than underlying serious pathologies
Don’t miss underlying serious disorder
47. I – Infections ( herpes stomatitis, UTI,
meningitis, osteomyelitis & so forth )
T –Trauma ( accidental/non accidental ),
testicular torsion
C - Cardiac ( congestive cardiac failure, SVT )
R – Reflux, reaction to medications/formulas
I – Immunizations, insect bites
E – Eye ( corneal abrasions, FB, glaucoma)
S – Surgical ( volvulus,intusseption, hernia)
50. Behavioral state, characterized by unexplained
paroxysms of inconsolable crying , lasting for
more than 3 hrs a day & occurring more than
3 days in a week, for a period of 3 weeks .
Occurs in 10-25% of infants
Onset is usually 2-3 wks of age , peaking at 6-
8 wks and remitting at 3-4 months of age
51. Episodes usually occurs during evening hours
Infant may grimace, pass flatus , clench
his/her fists and draw up his/her legs
Cry is prolonged ,loud, high pitched –
described as piercing
52. Colic is a diagnosis of exclusion
Exact cause of colic not known , many
possibilities thought of—
Gastrointestinal causes
Neuropsychological causes
Food allergies
parental misadventures
53. a) carbohydrate malabsorption
b) lactose in the diet, CMPA
c) increased gas in the infants with colic ??
d) behavioral factors such as feeding
abnormalities ,infant positioning while feeding
e) Psychological factors suggested possible
etiologies like underdeveloped parenting skills,
parental anxiety, stress
54. For diagnosis of colic,
routinely lab investigations
are not required, unless you
suspect something else
55. Overfeeding in an attempt to lessen crying
Feeding certain foods ,especially those with
sugar content , may increase amount of gas
in the intestines ( e.g. undiluted fruit juices )
Presence of excessive anger, fear, excitement
in household
Multiple factors as yet unknown
56. Reassuring the parents that colic is self-
limited. Encourage parental rest breaks,
developing strategies for crying episodes
Folk remedies ( herbal teas- licorice, dill
oil,fennel oil ) ?? Efficacy
Behavioral modifications-positioning of
infant during feeding, early response to
crying –shown not to be effective
57. Medications targeting GI system (
simethicone Vs placebo- demonstrated equal
improvement)
Dicyclomine has shown effect in some RCTs,
but issues of safety ( apnea ,other serious adv
effects) . Not recommended < 6 mths
? Changing formulas , ? Lactose free formulas
,addition of lactase in formula–No benefit
58. Low allergen diet in mother ( diet free of egg,
milk, nuts, wheat, artificial colors &
preservatives ).
Herbal remedies ( tea containing chamomile,
vervain, licorice, fennel etc) showed some
reduction in crying.
59.
60. I – Infections ( herpes stomatitis, UTI,
meningitis, osteomyelitis & so forth )
T –Trauma ( accidental/non accidental ),
testicular torsion
C - Cardiac ( congestive cardiac failure, SVT )
R – Reflux, reaction to medications/formulas
I – Immunizations, insect bites
E – Eye ( corneal abrasions, FB, glaucoma)
S – Surgical ( volvulus,intusseption, hernia)
61. Common clinical dilemma
Every case has to be individualised
History & clinical examination are main tools
Ordering unnecessary test add stress to
family & cost burden !
Sick child, poor growth ,inconsolable child
deserves investgations
Don’t forget possibility of abuse
Support, reassuarance needed in many
62. IF A CHILD DOESN’T CRY
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PEDIATRICIAN MIGHT!!!
