Symptoms » Crying infant » Book Sections

Crying and Irritability

Excessivecrying by infants and children is very disturbing to parents. Irritability(excessive sensitivity to any stimulus or irritant) is often accompaniedby inconsolable crying.

2 studies (Hunziker and Barr, 1986;St. James-Roberts and Halil, 1991) report that mean crying timein normal 1- to 3-mo-old infants was about 2 hrs/day. Morecrying occurred in the evening compared with other times of theday. As infants grew older, they were observed to cry less (Hunzikerand Barr, 1986).

Whenever excessive crying or irritabilityoccurs, it is important to determine its cause. Parents need anexplanation, so they can understand and cope with this problem.

Principal Causes of Crying and Irritability

1. Wellchild
   1. Physicaldisturbance
   2. Psychologic disturbance
   3. Colic
2. Ill child
   1. Infection
      1. Viral illness
      2. Acute otitis media
      3. Herpes gingivostomatitis
      4. Herpangina
      5. Gastroenteritis
      6. Urinary tract infection
      7. Meningitis
      8. Encephalitis
      9. Septicemia
   2. Trauma
      1. Fractures (skull, extremity, clavicle)
      2. Subdural hematoma
   3. Skin disorders
      1. Burn
      2. Hair tourniquet syndrome (hair wrappedaround a finger or toe)
   4. Gastrointestinal disorders
      1. Constipation
      2. Incarcerated inguinal hernia
      3. Intussusception
      4. Appendicitis
      5. Intestinal obstruction
      6. Gastroesophageal reflux/esophagitis
   5. Cardiovascular disorders
      1. Supraventriculartachycardia
   6. Central nervous system disorders
      1. Increasedintracranial pressure including pseudotumor cerebri
   7. Genitourinary disorders
      1. Testiculartorsion
   8. Eye disorders
      1. Corneal abrasion
      2. Foreign body
      3. Glaucoma
   9. Skeletal disorders
      1. Osteomyelitis
      2. Infantile cortical hyperostosis (Caffeydisease)
   10. Drug reaction
       1. DTaP immunization
       2. Neonatal narcotic and alcohol withdrawal
       3. Maternal drugs in breast milk (sympathomimetics)
       4. Other (sympathomimetics, antihistamines,atropinics, cocaine)
   11. Idiopathic

Clinical Features and Diagnosis

Well Child

Physical Disturbance

Physicaldisturbances that contribute to excessive crying in infants andchildren include hunger, thirst, diaper wetness, loud noise, teething,tiredness, restriction of movement, anal fissure, pruritic rash,and environmental temperature that is either too warm or too cold.

In older children, hunger and tirednessare most common physical factors contributing to excessive cryingand irritability.

Psychologic Disturbance

Psychologicdisturbances that contribute to excessive crying and irritabilityin infancy include abnormal mother–child interaction wherethe mother is unable to meet physical and emotional needs of herchild. The relationship is characterized by lack of contact, stimulation,and love.

Conversely, overstimulation with disruptionof feeding and sleeping patterns also may cause excessive cryingand irritability.

In older children, anxiety, depression,lack of parental love, insecurity, excessive strictness in family,frequent punishment, and other personal or family problems may causefrequent crying and emotional upset.

Colic

May be definedas recurrent crying spells lasting >3 hrs/dayfor ≥3 days/wk beginning at 2–4 wks of life.

Episodes occur at predictable timesof day and each episode lasts 30 mins to 2 hrs or longer.

Infants are difficult to console bynormal parental means, but when they are not crying, they appearwell and developmentally normal.

Episodes usually resolve by about 4mos of age.

Why colic occurs is unknown, but Barrand Gunnar (2000) have hypothesized that it may be due to decreasedability of some infants to regulate or modulate their responses.

Ill Child

Infectionand trauma are most common causes of excessive crying and irritabilityin ill children.

Most disorders listed below are discussedin other chapters.

History and physical exam are oftendiagnostic.

Infection

Viral illness

Acute otitis media

Herpes gingivostomatitis

Herpangina

Gastroenteritis

Urinary tract infection

Meningitis

Encephalitis

Septicemia

Trauma

Fractures (skull, extremity, clavicle)

Subdural hematoma

Skin disorders

Burn

Hair tourniquet syndrome (hair wrappedaround finger or toe)

GI disorders

Constipation

Incarcerated inguinal hernia

Intussusception

Appendicitis

Intestinal obstruction

Gastroesophageal reflux/esophagitis

Cardiovascular disorders

Supraventriculartachycardia

Central nervous system disorders

Increasedintracranial pressure including pseudotumor cerebri

Genitourinary disorders

Testiculartorsion

Eye disorders

Corneal abrasion

Foreign body

Glaucoma

Skeletal disorders

Osteomyelitis

Infantile cortical hyperostosis (Caffeydisease)

Drug reaction

DTaP immunization

Neonatal narcotic and alcohol withdrawal

Maternal drugs in breast milk (sympathomimetics)

Other (sympathomimetics, antihistamines,atropinics, cocaine)

Idiopathic

Diagnostic Approach

Excessivecrying or irritability must be taken seriously, especially whencomforting and consoling fail to remedy the situation.

Age of child and presence of illnessnarrow diagnostic possibilities. Complete history, including psychosocialand developmental history, and physical exam are often diagnostic.

Infant can have normal physical examwith occult trauma (skull or extremity fracture), so that radiographssometimes are necessary.

Placement of fluorescein drops in eyemay be diagnostic of corneal abrasion or foreign body.

If physical exam is normal and cryingdoes not persist after assessment, serious illness is unlikely.If crying persists, other investigations may be necessary, and theseare guided by history and physical exam.

References

1. Barr RG, Gunnar M. The "transientresponsivity" hypothesis. In: Barr RG, et al., eds. Cryingas a sign, a symptom, & a signal. London: Mac Keith Press,2000:41–66.
2. Barr RG, et al., eds. Crying as a sign, a symptom, & asignal. London: Mac Keith Press, 2000.
3. Berezin S, et al. Esophagitis as a cause of infantilecolic. Clin Pediatr 1995;34:158–159.
4. Berkowitz D, et al. "Infantile colic" asthe sole manifestation of gastroesophageal reflux. J Pediatr GastroenterolNutr 1997;24:231–233.
5. Brazelton TB. Crying in infancy. Pediatrics 1962;29:579–588.
6. Carey WB. The effectiveness of parent counseling inmanaging colic. Pediatrics 1994;94:333–334.
7. Hunziker UA, Barr RG. Increased carrying reduces infantcrying: a randomized controlled trial. Pediatrics 1986;77:641–648.
8. Mortimer EA Jr. Drug toxicity from breast milk? Pediatrics1977;60:780–781.
9. Pawel BB, Henretig FM. Crying and colic in early infancy.In: Fleisher GR, Ludwig S, eds. Textbook of pediatric emergencymedicine, 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2000:193–195.
10. Peirog S, et al. Withdrawal symptoms in infants withfetal alcohol syndrome. J Pediatr 1977;90:30–33.
11. Poole SR. The infant with acute, unexplained, excessivecrying. Pediatrics 1991;88:450–455.
12. Rogers WB. Fussy baby: a new cause. Pediatrics 1979;63:347–348.
13. Rudolph AM, ed. Rudolph's pediatrics, 20thed. Stamford, CT: Appleton & Lange, 1996.
14. Schmitt BD. Colic: excessive crying in newborns. ClinPerinatol 1985;12:441–451.
15. St. James-Roberts I, Halil T. Infant crying patternsin the first year: normal community and clinical findings. J ChildPsychol Psychiatry 1991;32:951–968.
16. Wolke D, et al. Excessive infant crying: a controlledstudy of mothers helping mothers. Pediatrics 1994;94:322–332.

Book Source Details

• Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
• Author(s): Paul S. Bellet
• Year of Publication: 2006
• Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.

Other Book Chapters Related to Crying infant

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Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics Authors: Paul S. Bellet Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 0-78172-899-1

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