Pediatrics, Crying Child

Background

One of the most challenging aspects of pediatric medicine is dealing with a child (usually < 1 y of age) presenting with nonspecific symptoms, such as crying and irritability.

Because of the child's inability to localize complaints, these symptoms can indicate a spectrum of disease ranging from a benign process, such as colic, to a life-threatening illness, such as meningitis.^{[1, 2]}

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History

• The child's medical history, including surgeries, hospitalizations, illnesses, pregnancy complications, allergies, and birth events, should be obtained.
• Present medicines and recent illnesses should be reviewed.
• An explanation of events, including feeding habits, bowel movements, urination, fever, sick contacts, level of activity, degree and duration of concerns, and ability to be consoled, should be obtained.

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Physical

• A complete and thorough physical examination should include the following: overall appearance, ability to be consoled, stability of vital signs, and temperature of the child.
• Other important aspects by system

  • Rashes, perfusion, or bruising
  • Head, ears, eyes, nose, and throat (HEENT) examination for anterior fontanel fullness, hydration status, scleral color, corneal abrasions, pupillary activity, retinal hemorrhages, otitis, pharyngitis, foreign bodies, or neck tenderness
  • Dental examination for new tooth eruptions
  • Chest evaluation for breath sounds and tachypnea
  • Cardiovascular examination for murmurs, tachycardia, or arrhythmias
  • Abdominal evaluation for tenderness and bowel activity, left lower quadrant (LLQ) masses suggestive of constipation, or vertical sausage mass consistent with intussusception
  • Genitourinary examination for hernias, torsion (eg, a bluish mark within the scrotal contents indicating a torsed epididymal appendix, which is painful but usually self limited), or strangulations by hair tourniquets
  • Rectal examination for blood or fissures
  • Evaluation of extremities for focal tenderness, arthritis, or hair tourniquets
  • Neurologic evaluation for overall activity level, responsiveness, and ability to be consoled

   

  

   

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Causes

Causes of crying and irritability in the young child can vary greatly from relatively benign conditions, such as colic (a diagnosis of exclusion), to life-threatening conditions, such as meningitis or even abuse.^[3]

The following is a partial listing, by systems, of potential causes of crying and irritability.

• Infections

  • Meningitis
  • Urinary tract infections
  • Appendicitis
  • Pneumonias
  • Sepsis
  • Otitis
  • Gastroenteritis
  • Local skin infections

   

  

   
• Trauma^[3]

  • Corneal abrasions
  • Strangulation of extremities or genitalia (by hair)
  • Fractures
  • Abuse (including shaken baby syndrome)
  • Burns
  • Subdural hematomas
  • Foreign bodies

   

  

   
• Dental/oral

  • Aphthous ulcers
  • Dental eruptions (with or without pericoronitis)

   

  

   
• Toxic or metabolic causes of irritability include any transient or persistent change in body chemistries.

  • These can be endogenous or exogenous in origin.
  • Anticholinergic adverse effects and antihistamine adverse effects in over-the-counter preparations
  • Toxic exposures (eg, cocaine) and electrolyte abnormalities (eg, hypoglycemia, hypocalcemia, hyponatremia) are among a few of the potential causes.

   

  

   
• Genitourinary concerns include testicular torsion, hernias, and urinary tract infections.
• GI causes include life-threatening conditions (eg, intussusception, gastroenteritis) to more self-limiting conditions (eg, fissures, formula intolerance, colic).
• Cardiovascular concerns include supraventricular tachycardia or other arrhythmias.
• Other causes of crying and irritability are possible; however, a good system-by-system history and physical examination should help identify or rule out most concerns.

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Laboratory Studies

• The history and physical examination findings of the crying child should direct laboratory studies.
• Most children presenting with the chief complaint of crying and irritability can be easily consoled, and a cause can be readily found.
• In other cases, the general appearance of the child and the ability of the child to be consoled can be reassuring. Although an immediate cause may not be found, an immediate workup and precise diagnosis may be unnecessary.
• In contrast, alarming items in the history and/or physical examination may make rapid diagnostic workup and treatment necessary.

  • For example, children with fever, temperature instability, lethargy, or inconsolability should have an age-appropriate workup for sepsis.
  • At a minimum, this includes a complete blood count (CBC), serum electrolytes, blood culture, urinalysis, and urine culture.
  • Also, consider a lumbar puncture if younger than 6 weeks of age or if directed by examination and chest radiography if respiratory symptoms exist.
  • Because children with urinary tract infections and gastrointestinal pathology may appear intermittently well, a urinalysis and stool guaiac should be considered even if the child is afebrile and clinically stable. A recent study supports the fact that urinary tract infections can be a common cause for crying even in afebrile children.^[4] This is especially true in the very young patients. Therefore, one should consider ruling out urinary tract infections for those with persistent crying, the very young, or ill-appearing patients.
  • If abuse or head trauma is suspected, a CT scan of the head and long bone radiographs should be considered.

   

  

   
• Children at risk for corneal abrasions, such as those with untrimmed nails or scratches on the face, should have an eye examination with fluorescein staining.
• An ECG should be obtained if any concern of cardiac instability exists.
• Abdominal ultrasonography and/or barium enema is necessary in suspected cases of intussusception.
• A toxicology screen should be performed if acute or chronic exposures are thought to exist.
• The items discussed above should be performed by individuals comfortable with the ED care of children (or under their consultation) and only if the history or physical examination suggests a disease that the diagnostic test could identify or rule out.

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Emergency Department Care

• Children presenting with crying and irritability require an extensive history and physical examination by someone comfortable with the care and management of children.
• Crying and irritability are vague symptoms; therefore, the overall appearance and stability of the child should guide the diagnostic workup.
• Even if the child appears healthy and is thought to have a benign, non–life-threatening condition (eg, colic), one needs to provide detailed instructions to the family regarding what signs are concerning and when to return for medical care.
• If the child appears ill, has fever, is inconsolable, is lethargic, or if other concerns of infection exist, a workup for sepsis must be performed.
• The remaining diagnostic concerns should be ruled out by a detailed history and physical examination based on specific findings and a directed evaluation (as outlined).
• Always take the most conservative approach if any significant diagnostic questions remain unanswered. This would include such items as screening laboratory or radiographic studies, especially if concern exists of an occult infection or underlying pathology (eg, intussusception). Under all circumstances, guarantee adequate follow-up care and immediate reevaluation if the concerns change or the child's condition worsens. One might also consider consultation with those who are more comfortable ruling in or ruling out potential concerns.

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Consultations

In all cases in which one is not absolutely comfortable with the diagnosis and treatment of a particular child, consult someone comfortable with the emergency care of children or a physician who knows the patient or family.

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Medication Summary

No single medication for the treatment of the broad spectrum of illnesses that can cause crying and irritability can be recommended. Specific therapy can be prescribed only after efforts at obtaining a diagnosis are successful. For example, a corneal abrasion would be treated by the appropriate topical ophthalmic antibiotic, while otitis media can be treated by any number of appropriate oral antibiotics.

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Further Inpatient Care

• Need for inpatient management is dependent upon the specific cause of crying and irritability.
• Hospitalization for observation may be necessary for children with unclear etiologies.

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Further Outpatient Care

• In many cases, a specific cause of crying and irritability may not be found.
• If life-threatening causes can be ruled out through history, physical examination, and appropriate screening studies, patients with resolution of symptoms and excellent follow-up care can usually be observed as outpatients. In these cases, close follow-up care should be arranged and families should be instructed to return immediately if any worsening occurs or if new concerns develop.

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Transfer

• If a crying child is seen by medical personnel unfamiliar with the care or scope of concerns related to a crying or irritable child, transfer to an appropriate facility might be considered.
• Regional centers with pediatricians or pediatric emergency medicine physicians might be appropriate for the stable child with further concerns but without an obvious source or for children requiring more specialized services than can be provided at the initial site of presentation for care (ie, outlying urgent care centers, general community EDs). Stabilization and initial management should take place for concerning life-threatening conditions (examples being lumbar puncture [LP] and appropriate antibiotics for concerns of possible meningitis).
• Establishment of a working relationship, potential phone consultations, and/or formal transfer agreements can help support and expedite any required transfers for additional care or treatment.

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