Crying is the only way for an infant to communicate. Crying can reflect that an infant’s basic needs (such as hunger, thirst, and the need for affection) are unmet, or it can represent significant distress (anger, discomfort and pain). When this crying is out of proportion or out of place, i.e. crying patterns deviate from the perceived “norm,” or when efforts to console a crying infant are exhausted, parents often seek help. However, challenges in evaluating infants may arise when crying is the only sign. A thorough, systematic, appropriate history and physical examination are needed.
On average, infants aged less than 12 weeks cry from 1 to 4 hours each day, with a peak at 6 to 8 weeks, which gradually improves by approximately age 10 weeks.
Non-pathological causes of crying
- Excessive tiredness is suspected if the infant’s total sleep duration per 24 hours falls more than an hour short of the “average” for their age. Average sleeps requirements:
- In newborns approximately 16 hours
- At age of 2 – 3 months approximately 15 hours
- Hunger – If a mother reports feeding less than every three hours and the baby is not gaining weight it may indicate inadequate milk supply.
- Air trapping – An infant may engulf air during breast feeding or during excessive crying, which may result in colic. Its back should be rubbed after feeding.
Common pathological causes of crying
The majority of unexplained crying does not indicate a serious or life-threatening, problem and is often a treatable illness. The three most common diagnoses are colic, acute otitis media, and constipation.
Evaluation of patient
The very first step for identifying the cause is to enquire the history of a patient. A detailed enquiry of onset, duration, and modalities should be done. Birth history, past medical history, family history, family status and environment should be considered. In cases of babies who are breast fed, the mother’s mental status, food habits, medications, illnesses etc. should be noted.
|History of present illness
|· Onset, duration, frequency and timing of crying episodes
· Was there any episode or event prior to crying, like fear, fright, reprimand etc.
· Attempted interventions to console and outcomes
· Associated activities/behaviors/modalities (sleep, feeding, relation to physical position, etc)
· History of similar episodes and any prior evaluations
· Any other symptoms associated with crying.
|· What was her mental status when she fed her baby last? Was baby crying after that?
· What she ate when she fed her baby last. Was baby crying after that?
· Any medication she is taking? And for what?
· Any diseases she has.
|· Prenatal and birth history (gestational age, birth weight, etc)
· Pregnancy and/or perinatal complications
· Prenatal screening results
· Substance use during pregnancy
· Mother’s mental status, food craving, food aversions, fear, dreams etc. during pregnancy.
|· If baby on breastfeeding – frequency, difficulties, maternal medications, supplements, and diet
· If baby on formula-feeding – type of formula and method of preparation (mixing and temperature of water used)
· Temporal relationship between crying and feeding
· Any unusual signs/symptoms during feeds (diaphoresis, cyanosis, choking/gagging, emesis, etc)
|· Normal voiding/stool patterns
· History of prior urinary tract infection or known anatomic abnormalities
· History of prior laxative, enema, or stool softener use
|Past medical history
|· History of prior illnesses/hospitalizations
· Developmental milestones, growth, and weight gain
· Current or recent medications
· Immunization status ( review specific vaccines recently given)
|· Congenital, genetic, or metabolic disorders
|· Home environment (stress, domestic violence, social services involvement)
· Exposure to tobacco, alcohol, or drugs in the home
After taking a detailed history it is important to examine patient from head to toe including every system of the body, to make a diagnosis and rule out other possibilities.
Systematic physical examination
Examine the patient and see how responsive he or she is dullness, drowsiness, facial expression, cyanosis, pale etc.
Check pulses, temperature and dehydration,
A child who cannot be consoled is may suggest a more serious etiology. Persistent, excessive crying beyond the time of the initial assessment can be predictive of a serious illness and should also be taken into account when performing the physical examination and determining management of the patient.
Head and neck
- Examine head for any ecchymosis, trauma. History of trauma may indicate towards hematoma.
- Excessive dullness with neck stiffness is an indication of meningitis. Usually high fever is present but not in all cases.
- Corneal abrasion Redness, lachrymation and photophobia with excessive crying may indicate corneal abrasion, which is very common in infants.
- Foreign body, hair in eye.
- Acute otitis media – examine ear for any discharge, sensitiveness of the affected area (otalgia) by noticing facial expression of infant during examination.
- Foreign body
- Rule out nasal obstruction either due to congestion or due to any foreign body
- Oral examination should be done to rule out thrush, stomatitis, pharyngitis and teething.
- Clavicle Fractures
In neonates, if there is a history of difficult delivery, shoulder dystocia or fetal macrosomia (large for gestational age) may indicate clavicular fracture and specially mid-clavicular fracture.
- Rib Fractures
Rib fractures have been identified as a cause of crying in infants and should raise suspicion for non-accidental trauma. On examination, these may be identified as bony step-offs or crepitus over the affected area.
Breast tissue, especially in neonates, should be examined for possible breast mass, abscess, or cellulitis as the cause of unexplained infant crying.
- Congenital Heart Disease And Heart Failure
Inspect for cyanosis (central or peripheral), edema (pericardium, ankle and sacrum). Palpate the pulses, character of pulse (collapsing, volume)
Infants with congenital heart disease may present with irritability and crying, as they may have trouble with feeding, etc.
Inspect general distension, any masses, visible peristalsis. Tightly palpate the abdomen, keep looking at the patients face for any change in facial expression. Rule out localized tenderness, rebound tenderness, ascites etc.
Crying with history of vomiting of gastric contents suggests GERD. This may resolve spontaneously by the age of 12 to 18 months in most of babies.
Should be ruled out where there is history of febrile illness and reduced fluid intake. Due to constipation there may be abdominal discomfort, usually a dull ache, which may or may not be related to defecation. In case of acute crying anal examination should be done to rule out anal fissure.
- Pyloric Stenosis
The classical presentation is with non-bilious vomiting that gradually increases in frequency and severity to become projectile in nature.
74% of children with intussusception initially presented with crying episodes. The index of suspicion should be high in an infant who presents with waves of crying and/or apparent abdominal pain who may also have vomiting and/or bloody stools, lethargy, or intermittent flexing of the lower extremities. A mass may or may not be present on examination, particularly if the intussuscepted bowel has already self-reduced prior to abdominal examination.
- Hirschsprung Disease
Abdominal distension, bilious vomiting and little or no passage of stool are indication of Hirschsprung Disease. Examination will reveal generalised distension, active bowel sounds and a narrow empty rectum on rectal examination. Withdrawal of the finger may be followed by passage of gas and meconium.
- Urinary Tract Infection
Abdominal pain and unexplained vomiting, loin tenderness
- Consider transillumination of an enlarged scrotum to differentiate between hydrocele and other causes of scrotal swelling. Also consider ultrasound imaging with Doppler flow and obtaining urinalysis studies if the diagnosis is unclear based on physical examination findings alone.
Fractures have been identified as a common presentation of abuse, and in infants aged < 1 year.
- Hypoglycemia/Nervous Irritability
Hypoglycemia in infants can have a variety of presenting signs, including jitteriness, abnormal or high-pitched cry, irritability, poor feeding, and seizures. A bedside glucose measurement is an easy and minimally invasive test that can provide a vastly important piece of information, especially in younger infants who have lower glycogen stores and lower physiologic reserve.
- Central Nervous System Infections
Irritability can be the presenting sign of a serious underlying infection (including meningitis and encephalitis) prior to development of a fever. If there are no focal findings to suggest a central nervous system infection, but the infant is ill-appearing or has inconsolable crying throughout the history and physical examination, prolonged monitoring and/ or admission with repeat vital signs and reexaminations should be considered, as more localizing signs may develop over serial examinations.
Non-accidental trauma can be a cause of crying, and evidence of these injuries is often manifested as new or old lesions on the skin of an infant or young child. Full exposure of the infant during physical examination is paramount to identifying these physical signs. Most frequent sites of bruises were over the anterior tibia and knee as well as on the forehead and upper legs of walkers.
- Skin infection like boil, cellulitis, rashes etc.
- Diaper rashes
After a careful physical examination, treatment is planned in the direction of any clue found from history and physical examination. In infants who came with a chief complaint of crying, the majority will not have significant underlying disease.
This is a spasmodic type of pain, which is self limiting and paroxysmal in nature, usually occurs towards evening, also termed “evening colic”. Infantile colic is defined as per the rule of three: “The period of crying lasts for 3 hours or more, lasting for 3 or more days per week for a minimum of 3 months.” It is self-limiting in most of infants until age six months, because physical activity increases by the age of six months (sitting, crawling, standing etc.)
- There is not a definite cause for infantile colic but many theories are proposed to explain it. Air trapping in stomach, cow’s milk protein intolerance, food allergy, hormones which affect intestinal peristalsis and psychological causes.
- Psychological causes include attention seeking in babies, fear and fright, mother-infant relationship and inter-parent relationships are equally important to address when making a diagnosis of infantile colic.
Usually infantile colic is a self limiting pain which improves gradually with age and increased physical activity of the infant. The first thing in management is to reassure the parents and caregivers.
Some rubrics related to infantile colic.
If colic develops after emotional disturbance in the mother, the following rubrics can be taken:
Remedies for infantile colic
A remedy should be selected on the basis of peculiar symptom as per each case. How is the infant reacting? Aggravating and ameliorating factors should be examined carefully.
Pain comes and goes suddenly. Episodes of screaming. Periodical pain. Pain in afternoon, around 3 pm.
- Nux vomica
Indicated especially when pain is ameliorated by flatus (carbo veg). Child is very irritable and cranky in nature.
Specially indicated due to time modality. Distention of abdomen with flatulence. Infant passes much flatus.
Pain especially in the evening. An otherwise calm and yielding child irritable during pain. Generalised amelioration in open air.
Well known remedy for very irritable child. Crying relived by only rocking, and starts crying again if rocking is stopped.
Colic is consequence of mothers mental state. Suppressed anger in mother. Indignation, mortification etc. Pain relived by pressure on abdomen.
Like Colocynthis and Staphysagria Ipecac is also a very good remedy for colic originating from mothers mental state. Mortification. Thirstless, colic associated with vomiting and nausea.
When the child is “good” all day, but screams and is restless all night.
The child cries terribly, and seems full of incarcerated flatus; it even turns blue all over during its caries. Sometimes it has frequent and bloody stools.
The child’s colic is relieved by pressing firmly upon its abdomen. When it is crying with colic, relief is obtained at once by carrying it with its abdomen resting upon the point of the nurse’s shoulder.
- Veratrum album-
Terrible colic with coldness of the forehead. Very cold feet with the colic. The sufferings cause a cold sweat to stand upon the surface, particularly upon the forehead.
- HUTCHISON’S Pediatrics, 2nd edition
- complete dynamics by Dr. Roger von Zandvoort.