The Inconsolable Infant: Just colic or a bad omen?
CASE
A 2-month-old male infant born by uncomplicated spontaneous vaginal delivery at 38 weeks presented with two days of crying and irritability. Mom stated the baby’s birth was normal and he has been growing and developing normally. Two days ago, he became fussy, and has been crying and inconsolable since. He has been feeding well and making normal wet diapers. A thorough review of systems identified no other associated signs or symptoms. The patient’s vital signs were normal. Physical exam was notable for a fussy but well-appearing baby boy. Mucous membranes were moist. Fontanelle was flat. Heart sounds were normal without murmurs. Pulses were full on all extremities. Abdominal exam was reassuring with no hepatosplenomegaly, no guarding, no masses and no obvious ecchymosis. He had normal suck and moro reflexes. His tone was good. A thorough skin exam revealed no abnormalities. There were no outward signs of trauma.
DIAGNOSIS
Infant colic
DISCUSSION
A REVIEW OF PEDIATRIC COLIC
Infants presenting with chief complaint of “crying” can be a diagnostic dilemma for the emergency medicine provider. One might be eager to write it off as simple colic, and in most cases, this is likely the answer. However, it is imperative that the emergency medicine provider remain astute and keep his or her differential initially broad, as the inconsolable infant can also portend badness.
Crying is a normal aspect of human behavior. Infants may cry for a variety of reasons ranging from hunger, need for attention, discomfort, or pain. [1] When crying is perceived to be excessive, or parents are unable to console their infant, it can cause parental angst. Thus far, no consensus has been reached on the definition of excessive crying, but in general infant colic is “excessive crying of unknown cause in otherwise well infants”. Traditionally it is defined by the Wessel’s criteria of fussing or crying more than three hours of the day for more than three days of the week. [2]
However, colic should only be diagnosed after exclusion of other causes of excessive crying. One study by Freedman, et al. retrospectively reviewed the incidence of serious underlying illness in all afebrile patients less than one year of age who presented with the chief complaint of crying, irritability, screaming, colic, or fussiness. After a total of 237 met enrollment criteria the authors found that a total of 12 (5.1%) of children had serious underlying etiologies, with urinary tract infections (UTI) being most common. [3]
THE DIFFERENTIAL DIAGNOSIS OF AN INCONSOLABLE INFANT
Various studies have shown that history and physical exam remain the most valuable aspects of the evaluation of the crying infant and should impact provider decisions to pursue further diagnostic workup. [3]
There are several useful mnemonic’s available to help you approach the crying infant, such as the one shown in Figure 1. Regardless of how you approach each patient encounter, the most important thing is to have a systematic approach to every case.
Figure 1. Mnemonic to remember potential causes of excess crying infancy. (Photo credit: Pediatric EM Morsels Dr. Sean Fox)
GENERAL APPROACH
Every infant that presents to the emergency department with the chief complaint of “crying” or “irritability” warrants a careful history and thorough physical exam. The differential diagnosis for crying is broad and involves every organ system. [4] With a systematic head to toe exam, the emergency medicine provider can be sure that they won’t miss the important signs of a “scary” cause of crying. Below is outlined a systems-based approach to the crying infant. [5]
SKIN:
First things first: expose the infant and perform a thorough skin exam. Ensure to look at fingers, toes, and any other appendage, including the genitourinary area, to search for hair tourniquets. Hair tourniquets are circumferential constrictions of body appendages by clothing fibers or a strand of hair that causes strangulation and can lead to ischemia. (Figure 2) For more information about hair tourniquets please see a past blog post by Dr. Sam Goldman: The Wound-Up Infant.
Figure 2. Hair tourniquet syndrome
After assessing appendages, the EM provider should then inspect the rest of the skin to search for evidence of dermatitis, cellulitis, burns, or other rashes that could suggest an underlying toxic process. Primary irritant diaper dermatitis is a common cause of infant discomfort. [5]
One must also look closely for evidence of bruising, which can be a sign of non-accidental trauma (NAT). A useful tool to remember when evaluating the bruised infant is “Can’t cruise, then shouldn’t bruise”. Documentation of normal skin findings such as birth marks and dermal melanoses (formally known as Mongolian spots) is important, as change in the patient’s baseline pattern on future evaluations could be indicative of abuse.
After careful inspection of the skin, the astute EM provider should then examine the rest of the body systems in a stepwise manner. I typically approach the patient from a “top down” approach, with HEENT system next.
HEAD, EYES, EARS, NOSE AND THROAT
Starting with the head, the provider should inspect the fontanelle. Is it sunken, concerning for dehydration? Is it bulging concerning for increased intracranial pressure? Providers should then assess the eyes for evidence of irritation, conjunctivitis, glaucoma, or foreign body. An old adage is that infants with excess crying should also be assessed for corneal abrasion, however, a study conducted on 96 one to twelve week old, asymptomatic, healthy infants demonstrated that 49% of them had corneal abrasions, however the mean crying times were not significantly different for children with and without corneal abrasions. Thus, physicians should be cautious when attributing excessive crying to corneal abrasions due to the possibility of missing a more serious condition. [1]
Infant ears should be inspected for evidence of otitis media, foreign body or bruising. Ear bruising is particularly concerning for NAT. The oropharynx should then be examined, with care to ensure that the entire oropharynx is visualized. Teething is a common cause of infantile distress. Providers should also look for evidence of stomatitis, which can present as oral lesions or ulcers and can represent HSV or coxsackie infections. In the younger infant group (especially less than 1 month of age), these findings may prompt further investigation with a full sepsis work-up to rule out a severe systemic infection. Thrush is another common cause of infantile discomfort. Bednar aphthae can also cause infantile distress, as they are infected wounds of the hard palate caused by chronic trauma from sucking.. (Figure 2) Though they typically do not require specific treatment, correcting the feeding position can prevent downstream feeding intolerance. Oropharyngeal bruising is always pathologic, and should prompt one to think of non-accidental trauma, as bruising can be caused by shoving something inside the mouth such as a bottle or pacifier. Notice a theme yet? Non-accidental trauma can literally show up anywhere and should not be missed!
Figure 2. Bednar aphthae [6]
CARDIOVASCULAR
Arrhythmias are another potential source of infantile distress. Paroxysmal supraventricular tachycardia is the most common arrhythmia in children. In many infants, such arrhythmias will be recognized at birth. However, some infants with no known history of fetal tachycardia may present with episodes of crying, irritability, poor feeding, pallor, diaphoresis and tachycardia. Typically, the heart rate of such infants will exceed 220 beats per minute and will be resistant to fluid boluses or attempts at calming the infant. [5] EKG will show absent p waves and minimal to no variability in heart rate.
Congenital heart disorders (CHD) affect roughly 1% of all live born infants and can present as infant crying or distress. While most cases of CHD will be diagnosed prenatally or during an infant’s birth hospitalization, some infants may be asymptomatic at birth, missed with routine postnatal screening and only develop symptoms after discharge. [7] A careful history, including asking parents about episodes of crying, pallor, diaphoresis or feeding difficulties, can help suggest the diagnosis in the emergency department.
The emergency physician should be sure to ask about symptoms such as fever and malaise to gauge the need to work the infant up for infective endocarditis or myocarditis. In general, infants with CHD are at increased risk for infective endocarditis. Thus, in any patient presenting with crying with a known history of CHD and any sign of underlying infection, these diagnoses must be considered. [1]
PULMONARY
A thorough pulmonary history should be obtained from parents, including any history of chronic pulmonary disease such as a recent pneumonia, cystic fibrosis, or bronchopulmonary dysplasia. Though less likely in this young age group, one should always ask about the possibility of a foreign body in the airway, particularly if other young children are around the infant. Unexplained foreign body in the airway can also be a sign of non-accidental trauma, so if the story is funny or the foreign body cannot be explained, consider NAT!
In infants with concern for possible trauma, the patient should be assessed for evidence of rib fracture or pneumothorax on exam, and appropriate imaging should be obtained if high clinical suspicion.
GASTROINTESTINAL
The inconsolable infant could have various gastrointestinal causes of discomfort ranging from reflux or constipation to food allergies, anal fissures, or acute surgical abdomens. In general, as with most etiologies of infantile crying, the history and physical exam is crucial. Any infant presenting with a combination of abdominal distension, abdominal tenderness, bloody stools or persistent vomit warrants a thorough abdominal exam and further work-up for GI pathologies.
Examination of the crying infant’s abdomen can pose a challenge due to contraction of the abdominal musculature with crying, but it is crucial that the EM provider feels confident in their abdominal exam. Trying to palpate the infant’s abdomen during inhalation as opposed to exhalation might aid in getting a more reliable exam. In the case of volvulus or intussusception, the infant will likely present with periodic but severe attacks of crying, and eventually may demonstrate abdominal distension, vomiting, fever and at later stages, profound shock. In fact, screaming attacks is considered the second most common clinical manifestation of intussusception, second only to vomiting. [1] For more information on intussusception please refer to this past post by Dr. Robyn Levine: Intussusception Deception: An Atypical Presentation.
A stooling pattern history should be obtained, particularly focusing on whether or not there has ever been blood in or on the stool and how often the patient is stooling. The rectum should be closely examined for evidence of anal fissures. If the patient presents with associated symptoms of excessive vomiting or failure to thrive, GERD should be a consideration. In infants presenting with loose stools, bloody or non-bloody, the possibility of food allergies or food protein-induced enterocolitis should be considered. For more information on FPIES, consider this post by Dr. Mary Ledoux: FPIES: Expanding the Differential for Hypotension in the Pediatric Patient.
Necrotizing enterocolitis (NEC) should be considered in the neonate, particularly in infants with a history of prematurity presenting with fussiness. NEC typically develops within the first two weeks of life in a premature infant and often presents initially as irritability and/or inability to tolerate feeds. The EM provider will often note abdominal distension on exam and the infant may have bilious emesis and bloody stools. Diagnosis is typically confirmed by pneumatosis intestinalis, or air bubbles seen in the wall of the intestine on an abdominal x-ray.
GENITOURINARY
After inspecting the GU area for hair tourniquets, the EM provider should then thoroughly inspect the area for evidence of hernias or torsion, both of which require urgent surgical attention. [1] An inguinal hernia will present as swelling in the groin area. If incarcerated, it is typically tender and often accompanied by nausea and vomiting.
In males, testicular torsion is caused by sudden rotation of the testis around its axis, leading to blocked venous drainage, reduced arterial perfusion, and eventually infarction of the tissue. On exam, the EM provider will notice tenderness to the scrotal area often with swelling and redness acutely, later followed by signs of ischemia. This represents a surgical emergency.
Females are prone to ovarian torsion, but it represents a rarer finding when compared to male testicular torsion, especially in infants. Caused by sudden rotation of the ovary about its vascular axis, torsion ultimately lead to venous obstruction, infarction and necrosis and can subsequently result in peritonitis. Infants commonly present with excess crying and are found to have a tender abdomen on exam, making it hard to distinguish from other intraabdominal emergencies. The key is to always consider it, and diagnosis can be made with ultrasound. [5] Rarely, ovaries can also herniate with intestinal contents, leading to similar discomfort.
In males in particular, one should also assess for evidence of balanitis or other skin infections. Obtaining a urinalysis to screen for infections in infants with an otherwise normal exam but continued unexplained crying is also reasonable to assess for underlying urinary tract infection. [1]
MUSCULOSKELETAL
Assessing for traumatic injuries in the inconsolable infant is vital. The infant’s body should be carefully palpated in a systematic manner, including all extremities, to assess for swelling or tenderness that could represent an underlying fracture. Typically, infants will present fussy or irritable, but with careful examination it may become more apparent if an infant is refusing to move a limb or has subtle swelling. In general, if an infant under the age of one is found to have any fracture, NAT should be high on the differential, and often these children require admission for further workup including skeletal survey.
Aside from traumatic injuries, the EM provider must be vigilant in assessing for any evidence of bone or joint warmth, erythema, or swelling that could represent an underlying infectious process such as septic arthritis or osteomyelitis. In general, if one suspects such etiologies, lab work including cbc and inflammatory markers are indicated along with plain radiographs of the affected area. If imaging is equivocal but laboratory work is concerning for infectious process, MRI is typically the go-to imaging modality in this age group. For more information on the work-up of pediatric osteomyelitis or septic arthritis, please see a previous post by Dr. Cameron Gettel: Approach to the Pediatric Limp.
NEUROLOGIC
Finally, a careful neurologic exam should be performed in all infants presenting to the emergency department, regardless of chief complaint. Arguably one of the most essential neurologic etiologies of infant crying and distress includes meningitis, with bacterial and HSV meningitis requiring prompt recognition and treatment in order to prevent devastating consequences. Early signs of meningitis can be subtle, but in general there appears to be two distinct clinical presentations observed in infants with meningitis. The first presentation is characterized by severe sepsis with evidence of mottled limbs, skin hemorrhage, and tachycardia, and nearly always suggests underlying meningococcal disease. The second presentation is less obvious, as infants can present with subtle findings such as abnormal crying, increased irritability, non-specific GI findings such as vomiting or anorexia, or can present with more obvious findings such as bulging fontanel and seizures. Lumbar puncture must be performed in the emergency department expeditiously in infants presenting with such findings. [5]
In neonates presenting with crying or irritability, a thorough birth history should be obtained, including history of maternal drug use, as neonates in drug withdrawal can often present as irritable and difficult to console. [1]
Infants with intracranial hemorrhage, cerebral edema, or hydrocephalus can present with crying, irritability, lethargy and decreased activity. In general, infants with inflicted traumatic brain injuries often present without any external signs of trauma, thus clinicians must maintain a high index of suspicion for intracranial pathologies and consider head imaging if there is any suspicion. [1]
CONCLUSION
In general, the ED provider should be sure to initially keep a broad differential when a patient presents with chief complaint of “crying”. History and physical remain the most important aspects when assessing an infant with excess crying. If after a careful history and physical exam, there are no obvious causes of excess crying and no indications have arisen for need for further lab or imaging studies, then the diagnosis of colic may be considered. The mainstay of treatment for infantile colic includes providing parental support and help coping with their infant’s symptoms and attempting to reduce the risks of parental stress and depression as well as child abuse.[2] All families should be offered psychosocial support, often in the form of social work consultation or close outpatient follow-up to provide on-going support. Calling the patient’s pediatrician can be an important and helpful step to help provide ongoing support to the family beyond the walls of your ED.
CASE RESOLUTION
You provide reassurance to the patient’s mother and consult social work for maternal support and then discharge the patient home with pediatrician follow-up.
TAKE-AWAYS
In general, colic should only be diagnosed after exclusion of other causes of excessive crying.
A thorough history and review of systems is necessary to gain insight into potential factors contributing to the crying infant’s presentation.
The emergency medicine provider must have a systematic approach to the physical exam in the infant presenting with excess crying.
When diagnosing infantile colic, parents should be offered psychosocial support to help with coping and to prevent long-term adverse events such as parental depression or child abuse.
AUTHOR: Michelle Myles, MD is a second-year emergency medicine resident at Brown University/Rhode Island Hospital
FACULTY REVIEWER: Meghan Beucher, MD is a pediatric emergency medicine physician at Hasbro Children’s Hospital
REFERENCES
Herman M, Le A. The crying infant. Emerg Med Clin North Am. 2007;25(4):1137-vii. doi:10.1016/j.emc.2007.07.008
Sung V. Infantile colic. Aust Prescr. 2018;41(4):105-110. doi:10.18773/austprescr.2018.033
Freedman SB, Al-Harthy N, Thull-Freedman J. The crying infant: diagnostic testing and frequency of serious underlying disease. Pediatrics. 2009;123(3):841-848. doi:10.1542/peds.2008-0113
Allister L, Ruest S. A systematic approach to the evaluation of acute unexplained crying in infants in the emergency department. Pediatr Emerg Med Pract. 2014;11(3):1-18.
Matijasic N, Plesa Premilovac Z. Inconsolable Crying in Infants: Differential Diagnosis in the Pediatric Emergency Department. Clin Pediatr (Phila). 2019;58(2):133-139. doi:10.1177/0009922818798389
Theiler M, Schwieger-Briel A, Cont M, et al. Bilateral palatine ulcers in a neonate: Bednar’s aphthae. Archives of Disease in Childhood 2018;103:1020.
Tennant PW, Pearce MS, Bythell M, Rankin J. 20-year survival of children born with congenital anomalies: a population-based study. Lancet. 2010;375:649-656.