Irritability

Irritability: Excerpt from In A Page: Pediatric Signs and Symptoms

The differential diagnosis for irritability is large and varied. In young children irritability may be the only presenting complaint for life-threatening disease states. A careful history and physical exam are needed to narrow the differential so that only indicated tests are performed.

Differential Diagnosis

• General/nutritional
  –Colic
  –Teething
  –Malnutrition/hunger
  –Atopic dermatitis
• Infectious
  –Otitis media
  –Meningitis, encephalitis
  –Stomatitis
  –Gastroenteritis
  –Osteomyelitis, diskitis, septic arthritis
• Trauma
  –Abuse/shaken-baby syndrome
  –Fracture
  –Hair tourniquet (e.g., on digit or penis)
  –Corneal abrasion or foreign body in eye
• Gastrointestinal
  –Constipation
  –Gastroesophageal reflux
  –Anal fissures
  –Milk protein allergy, celiac disease
• Surgical
  –Testicular torsion
  –Incarcerated hernia
  –Intussusception
• Metabolic
  –Electrolyte disturbances
  –Hypoglycemia
• Medications/drugs
  –Narcotic withdrawal, fetal alcohol syndrome
  –Medications (e.g., URI preparations)
  –Lead or mercury poisoning
• Hematologic
  –Leukemia
  –Iron deficiency anemia
  –Sickle cell with vaso-occlusive crisis
• Cardiac/respiratory
  –Myocarditis, pericarditis, arrhythmias
  –Congestive heart failure
  –Respiratory failure, hypoxia
  –Carbon monoxide poisoning
• Neurological
  –Increased intracranial pressure
  –Subdural hematoma
  –Migraines
• Other
  –Psychosocial
  –Urinary retention
  –Glaucoma

Workup and Diagnosis

• History
  –Medications, past medical history
  –Duration of symptoms, time of day child is irritable
  –Anything that makes the irritability better or worse
  –Feeding difficulties
  –History of trauma
  –Associated symptoms (e.g., URI, vomiting, diarrhea)
  –Psychosocial stressors in the family
• Physical exam
  –Vital signs
  –Signs of abuse or infection
  –Hair tourniquets
  –Fluorescein the eyes for corneal abrasion

• Labs/studies (based on clinical suspicion)
  –CBC with differential, blood culture, urinalysis and urine culture, lumbar puncture, sedimentation rate and C-reactive protein for infectious cause
  –X-rays for possible fracture
  –Brain MRI or CT scan for tumors or hematomas
  –Bone scan for osteomyelitis and diskitis
  –Joint aspiration and culture for septic arthritis
  –Electrolytes, including glucose
  –Echocardiogram/ECG for cardiac defect
  –Abdominal X-rays or ultrasound for surgical abdomen
  –Air or contrast enema for intussusception
  –Drug screen, lead, or carboxyhemoglobin level

• Consult ophthalmology to look for retinal hemorrhages in shaken-baby syndrome

Treatment

• Stabilize the patient (ABCs)
• Pain can be treated with acetaminophen or ibuprofen; in more severe cases, a narcotic may be required
• Treat infections with the appropriate antibiotics
• Consult subspecialists, such as hematology, surgery, orthopedics, or neurosurgery, as needed
• Correct electrolyte disturbances
• Discontinuation of causative medications or toxins
• Educate the family about colic and teething, treatments, and natural history
• Social work involvement as needed

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: Irritable bowel syndrome (Professional Guide to Diseases (Eighth Edition))

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