Crying

Crying: Excerpt from The 5-Minute Pediatric Consult

Mark F. Ditmar, MD

Crying - BASICS

Crying - description

• Crying is usually a normal physiologic response to distress, discomfort, or unfulfilled needs.
• Crying is felt to be potentially pathologic if it is interpreted by caregivers as differing in quality and duration without apparent explanation and/or persists without consolability beyond a reasonable time (generally 1–2 hours).

Crying - etiology

• The most likely cause of inconsolable crying in the 1st few months of life is, without question, infantile colic. Practitioners must be familiar with the clinical pattern of infantile colic, so that deviations are readily recognized.
• Patients’ families often suggest teething as a cause of excessive crying (as well as fever, diarrhea, rashes, etc.). Objective data do not support a strong association.
• Be careful in ascribing symptoms and signs to teething.

Crying - DIAGNOSIS

General goal is to decide if the crying represents a normal physiologic response, a protracted multifactorial physiologic/developmental response (colic), or a potentially pathologic problem.

• Phase 1: How urgent is the need for evaluation? A classic and difficult triage issue. One must identify the periodicity of the problem, associated symptoms, impression of wellness, and parental anxiety/reliability.
• Phase 2: When in doubt, particularly if colic seems unlikely, see the patient as soon as possible.

Crying - signs & symptoms

Crying - history

• Colic less likely as a cause if onset after 1 month of age or persistent in infants >4 months
• Recurrent episodes, particularly with a diurnal or evening pattern, are more likely due to colic.
• Crying shortly after feeding suggests aerophagia or gastroesophageal reflux; 1 hour after feeding suggests formula intolerance. A rare cause of postprandial crying is anomalous coronary arteries.
• Fever indicates potential need for evaluation of meningitis, other infections.
• Paradoxically increased crying (attempts at consolation make the crying worse, especially with lifting, rocking) can be seen in meningitis, peritonitis, long-bone fractures, arthritis.
• Stridor implies possible upper airway obstruction (mechanical, functional).
• Expiratory grunting indicates higher likelihood of significant pathologic cause of crying (especially cardiac, respiratory, and/or infectious disease).
• Cold symptoms and/or day care attendance increase likelihood of otitis media.
• Vomiting increases likelihood of pathologic gastrointestinal cause (e.g., obstruction, gastroesophageal reflux with possible esophagitis), particularly in infant <3 months, or CNS disease.
• Overfeeding or underfeeding, excessive air swallowing, inadequate burping, improper formula preparation may contribute to excessive crying.
• Recent fall or trauma may indicate possible fracture, increased intracranial pressure, abuse.
• Documented weight loss outside of the 2 week neonatal period suggests an organic cause.

Crying - physical exam

• Tympanic membrane with loss of landmarks, poor mobility, and swollen canal indicate otitis media, otitis externa, foreign body.
• Tenderness on palpation of extremities, clavicle, or scalp, or painful or decreased range of motion of joints suggests fracture, subluxation, osteomyelitis, septic arthritis.
• Conjunctival redness, eye tearing, scratches near the eye suggest corneal abrasion (fluorescein testing of eye warranted) or foreign body in eye (eversion of lid recommended).
• Impacted or bloody stool on rectal exam, abdominal mass suggest constipation or intussusception.
• Geographic scars, frenulum tears, retinal hemorrhages, suspicious bruises, burns, decreased weight/height ratio suggest neglect/abuse (physical, emotional).
• Bulging or full fontanel (especially in upright, quiet infant) indicates possible increased intracranial pressure (meningitis, subdural hematoma, vitamin A toxicity).
• Edema of individual toes, fingers, or penis suggest hair tourniquet syndrome.
• Tender swelling in inguinal or scrotal area may indicate incarcerated hernia, testicular torsion.
• Heart rate >200 with minimal variability indicates possible supraventricular tachycardia.
• Hypothermia suggests infections or hypothyroidism.

Crying - tests

• Stool for occult blood: Possible intussusception, anal fissure
• Fluorescein testing of eye: Corneal abrasion (may occur without significant conjunctival redness)
• Urinalysis/urine culture: UTI
• Urine toxicology screen: Drug withdrawal (neonatal), ingestions, passive exposures (e.g., cocaine)
• Pulse oximetry: Hypoxia (from cardiac causes) may cause increased irritability.
• Electrolyte panel/blood glucose: Endocrine or metabolic disturbance, especially if abnormal sodium, hypoglycemia, significant acidosis, or elevated anion gap

Crying - differencial diagnosis

• Congenital/Anatomic:
  • Intussusception
  • Gastroesophageal reflux/esophagitis
  • Volvulus
  • Gaseous distention (secondary to improper feeding or burping)
  • Incarcerated hernia
  • Peritonitis (acute abdomen)
  • Testicular/ovarian torsion
  • Constipation
  • Anal fissure
  • Meatal ulceration
  • Glaucoma
  • Urinary retention (secondary to posterior urethral valves)
  • Cardiac—anomalous coronary artery, hypoxia, CHF
• Infectious:
  • Otitis media/externa
  • UTI/Pyelonephritis
  • Stomatitis/gingivitis
  • Meningitis/encephalitis
  • Discitis
  • Gastroenteritis
  • Arthritis, septic
  • Osteomyelitis
  • Perianal cellulitis
  • Balanitis
  • Dermatitis (especially pruritic as in scabies or painful as in staphylococcal scalded skin syndrome)
• Toxic, environmental, drugs:
  • Neonatal drug withdrawal
  • Prenatal/Perinatal cocaine exposure
  • Immunization reactions (especially DPT)
  • Cow milk intolerance
  • Isolated fructose intolerance
  • Drug reactions (especially antihistamines, pseudoephedrine, phenylpropanolamine), including maternal medications in breast milk
  • Vitamin A toxicity
  • Carbon monoxide exposure
  • Emotional/physical neglect
• Trauma:
  • Corneal abrasion
  • Foreign body (hypopharynx, eye, ear, nose)
  • Skull fracture/subdural hematoma
  • Intracranial hemorrhage
  • Retinal hemorrhage (e.g. shaken baby syndrome)
  • Other fractures (especially extremities)
  • Hair tourniquet syndrome (encircling finger, toe, penis, clitoris)
  • Open diaper pin
  • Bite (human, animal, insect)
• Genetic/Metabolic:
  • Sickle cell crisis
  • Phenylketonuria
  • Hypothyroidism
  • Electrolyte abnormalities (especially sodium)
  • Hypoglycemia
  • Hypocalcemia
  • Hypercalcemia
  • Inborn error of metabolism
• Allergic/inflammatory:
  • Cow milk allergy
  • Celiac disease (gluten enteropathy)
• Functional:
  • Parental expectations/responses
• Miscellaneous:
  • Overstimulation
  • Persistent night awakening
  • Night terrors
  • CHF
  • Caffey disease (infantile cortical hyperostosis)
  • Dysrhythmia (especially supraventricular tachycardia)
  • IV infiltration
  • Autism
  • Teething
  • Headache/migraine
  • Temperament
  • Colic
  • Discomfort (cold, heat, itching, hunger)
• Clinical pearls:
  • Quality of cry: Subjective interpretation can be helpful.
    • High-pitched (shrill, piercing) crying in short bursts: Associated with CNS pathology, especially with increased intracranial pressure
    • High-pitched crying in longer bursts: Seen in small-for-gestational age infants, neonatal drug withdrawal
    • Hoarse crying: Seen in hypothyroidism, laryngeal diseases, hypocalcemic tetany
    • Weak crying: May be seen in neuromuscular disorders, infant botulism, and/or the very ill infant
    • Catlike cry: Can be associated with cri du chat syndrome (5p syndrome or absence of short arm of chromosome 5)
  • Neonatal drug withdrawal has other characteristic findings in addition to excessive crying:
    • Wakefulness
    • Irritability
    • Tremulousness, temperature variation, tachypnea
    • Hyperactivity, high-pitched persistent cry, hyperacusis, hyperreflexia, hypertonia
    • Diarrhea, diaphoresis, disorganized suck
    • Rub marks, respiratory distress, rhinorrhea
    • Apnea, autonomic dysfunction
    • Weight loss or failure to gain weight
    • Alkalosis (respiratory)
    • Lacrimation
  • Factors that may help alert you to make a referral include:
    • Infant appears ill (e.g., pallor, grunting, poor arousability, poor response to social overtures)
    • Weight loss or abnormal development (implies much higher likelihood of an organic cause)

Factors that make this an emergency include:

• Suspicion of meningitis: Stiff neck, bulging fontanel, fever (especially infants <2–3 months)
• Suspicion of intestinal obstruction: Vomiting (especially bilious or projectile), mass on abdominal palpation, and/or bloody stools
• Suspicion of incarcerated hernia or testicular/ovarian torsion
• Evidence of cardiac compromise (CHF, supraventricular tachycardia): Tachycardia, poor perfusion (capillary refill >3 seconds, poor distal pulses), rales
• Evidence of acute dehydration: Weight loss, decreased urine output, orthostatic changes, poor perfusion
• Evidence of child abuse or neglect

Crying - bibliography

1. American Academy of Pediatrics Committee on Drugs. Neonatal drug withdrawal. Pediatrics. 1998;101:1079–1088. Erratum in Pediatrics 1998;102(3 pt 1):660.
Barr RG, Hopkins B, Green JA, eds. Crying as a Sign, a Symptom and a Signal. London: Cambridge University Press; 2000.
2. Evanod G. Infant Crying: A clinical Conundeum. J Pediatr Health Care 2007;21:333–338.
3. Poole SR. The infant with acute, unexplained, excessive crying. Pediatrics. 1991;88:450–455.
4. Reijnveld SA, vanderWal MF, Brugman E. et al. Infant crying and abuse. Lancet. 2004;364:1340–1342.
5. Trocinski DR, Pearigen PD. The crying infant. Emerg Clin North Am. 1998;16:895–910.

Crying - CODES

Crying - icd9

780.92 Excessive crying of infant

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

More About Cri-du-chat syndrome

• Back to disease: Cri-du-chat syndrome: Introduction
• Next Book Extract About Cri-du-chat syndrome: Deletion Syndrome (Digeorge Syndrome) (The 5-Minute Pediatric Consult)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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