Irritable Infant

[Section Outline]

Description
Etiology

Author:

David H.Rubin

Description

Most children have some period of the day when they are most irritable, usually toward the evening:
- Normal infant crying ranges from 3 hr/d at 6 wk of age and decreasing until 16 wk of age
- During the first 6 mo of life, 1-mo olds have the highest prevalence of crying
Irritability is based on a comparison with the child's normal behavior pattern
Colic or excessive infant crying of unknown cause, is the most common cause of inconsolable crying in infants, occurring in as many as 25% of healthy children:
- Episodes of paroxysmal screaming accompanied by drawing up knees and oftentimes passage of flatus
- Usually begins at 2-3 wk and may continue through 12 wk, 3 hr/d
- Diagnosis of exclusion

Etiology

Bites: Spider/insect bite
Burn
Cardiac (supraventricular tachycardia, congestive heart failure, aberrant left coronary artery, coarctation of the aorta, endocarditis, myocarditis)
Child abuse
Corneal abrasion/foreign body (eyelash) in eye
Diaper pin
Diphtheria, pertussis, and tetanus (DPT) and other vaccine reactions
Endocrine/metabolic (inborn errors of metabolism, metabolic acidosis, hypernatremia, hypoglycemia, hypocalcemia, hyperthyroid - direct or by transplacental passage of maternal thyroid-stimulating immunoglobulins)
Foreign body, fracture, tourniquet (hair around digit or penis)
Gl (gastroenteritis, colic, gastroesophageal reflux, esophagitis, volvulus, malrotation constipation, cow's milk protein intolerance, anal fissure, intussusception, appendicitis)
Genitourinary (incarcerated hernia, testicular torsion, genital tourniquets, urinary retention) or localized
Infection: Systemic
Iron deficiency/anemia
Medications/toxins: Aspirin, antihistamines, atropine, adrenergics, home remedies, new prescription, mercury)
Meningitis
Minor acute infections (upper respiratory infection, otitis media, thrush, gingivostomatitis)
Neurologic (increased intracranial pressure: Mass, hydrocephalus, intracranial hemorrhage, hematoma - subdural, epidural, skull fracture)
Osteomyelitis
Parental anxiety
Pneumonia
Sickle cell crisis
Splinter
Teething
Trauma: Nonaccidental, SDH, fractures, shaken baby
UTI
Vascular

Diagnosis ⬆ ⬇

[Section Outline]

Signs and Symptoms
Essential Workup
Diagnostic Tests & Interpretation
Differential Diagnosis

Signs and Symptoms

Vital signs
Chief complaint
Chronology of events

History

Obtain complete history (including neonatal history) and information regarding routine feeding, crying

Physical Exam

Assess vital signs including rectal temperature and pulse oximetry
Measure and plot for percentiles: Height, weight, and head circumference
Perform a thorough physical exam with infant completely undressed

Essential Workup

This is usually directed by a comprehensive history and physical exam. Specific studies may be obtained

Diagnostic Tests & Interpretation

Lab

Limited value when used as screening tests
CBC, urinalysis, chemistries, and cultures as indicated by history and physical exam
Stat blood glucose at bedside if indicated
Stool hemoccult test if GI signs or symptoms

Imaging

Chest radiograph to exclude cardiopulmonary disease
Skeletal survey, if indicated
CT scan of the head, chest, etc. usually directed by history and physical exam
Contrast radiograph studies such as barium enema for specific indications

Diagnostic Procedures/Surgery

Fluorescein eye exam
ECG

Differential Diagnosis

See Etiology above. It is essential to distinguish benign, self-limited conditions from those that might be life threatening

Treatment ⬆ ⬇

[Section Outline]

Prehospital
Initial Stabilization/Therapy
ED Treatment/Procedures
Medication

Prehospital

As determined by history, physical exam, and lab studies

Initial Stabilization/Therapy

Manage underlying conditions; stabilize airway, breathing, and circulation (ABCs)
Immediate removal of hair tourniquets and /or splinters

ED Treatment/Procedures

Initial evaluation of the child focusing on parent-child interaction and then on potential underlying conditions
Colic responds to soothing, rhythmic activities, avoiding stimulants (coffee, cola), minimizing daytime sleep:
- Soy or hydrolyzed casein formula may be transiently beneficial
- Parents must reduce stress
- No proven pharmacologic therapy
- Probiotics may be useful
Support, empathy, close follow-up
Prolonged observation of the child is usually appropriate

Medication

Dependent on the underlying condition

First Line

Dependent on the underlying condition

Second Line

Dependent on the underlying condition

Follow-Up ⬆ ⬇

[Section Outline]

Disposition
Follow-up Recommendations

Disposition

Admission Criteria

Life-threatening underlying condition
Significant parental stress secondary to crying infant

Discharge Criteria

No serious condition
Functional and supportive family
Excellent follow-up is essential; parents must feel that their observations and concerns are not being ignored. Close follow-up and ongoing observation are mand atory to reevaluate the child and provide support to the family

Issues for Referral

Determined by specific specialty-related issues

Follow-up Recommendations

Long-term follow-up strongly recommended

Pearls and Pitfalls ⬆ ⬇

Address life-threatening/serious causes of irritability first:
- Cardiovascular: Supraventricular tachycardia, congestive heart failure, endocarditis/myocarditis
- Neurologic: Subdural/epidural, meningitis, intracranial hemorrhage, increased intracranial pressure, skull fracture
- Gl: Volvulus, intussusception, appendicitis, peritonitis
- Metabolic: Metabolic acidosis, electrolyte disturbances
- Genitourinary: UTI, torsion of testis, incarcerated hernia
- Infection: Systemic or localized
- Pulmonary: Foreign body, pneumothorax, pneumonia
- Dermatologic: Strangulated digit
- Toxicologic: Toxic ingestion, immunization reaction
- Trauma
- Ophthalmologic: Corneal abrasion, glaucoma
- Other: Child abuse, transplacental passage of maternal medications that may cause irritability
Detailed history and complete physical exam in the noncritically ill child is crucial before obtaining any lab or radiologic studies

Additional Reading ⬆ ⬇

BenjaminJS, ChongE, RamayyaMS. A preterm, female newborn with tachycardia, hypertension, poor weight gain, and irritability . Clin Pediatr (Phila). 2012;51(10):994-997.
ChuaC, SetlikJ, NiklasV. Emergency department triage of the “incessantly crying” baby . Pediatr Ann. 2016;45(11):e394-e398.
FrenchLK, CampbellJ, HendricksonRG. A hypertensive child with irritability and a rash . Pediatr Emerg Care. 2012;28(6):581-583.
HermanM, LeA. The crying infant . Emerg Med Clin North Am. 2007;25(4):1137-1159.
KennyP. Excessive crying in infants in the first months of life: A review . Arch Argent Pediatr. 2016;114(4):368-374.
McGannJ, ManoharJ, HiscockH, et al. Caring for crying babies; a mixed methods study to understand factors influencing nurses' and doctors' management of infant colic . J Paediatr Child Health. 2018;54(6):653-660.
PawelBB, HenretigFM. Crying and colic in early infancy. In: FleisherGR, LudwigS, eds. Textbook of Pediatric Emergency Medicine. 6th ed.Philadelphia, PA: Lippincott; 2010.
WardTR, FalconerJA, CravenJA. An irritable infant and the runaway redback: An instructive case . Case Rep Emerg Med. 2011;2011:125740.
WolkeD, BilginA, SamaraM. Systemic review and meta-analysis: Fussing and crying duration and prevalence of colic in infants . J Pediatr. 2017;185:55-61.

Codes ⬆

ICD9

780.91 Fussy infant (baby)
780.92 Excessive crying of infant (baby)
789.7 Colic

ICD10

R10.83 Colic
R68.11 Excessive crying of infant (baby)
R68.12 Fussy infant (baby)

SNOMED

444951002 fussy infant (finding)
162214009 Crying infant (finding)
35363006Infantile colic (finding)
247361008 Evening colic (finding)

section name header

Basics ⬇

Diagnosis ⬆ ⬇

History

Physical Exam

Lab

Imaging

Diagnostic Procedures/Surgery

Treatment ⬆ ⬇

First Line

Second Line

Follow-Up ⬆ ⬇

Admission Criteria

Discharge Criteria

Issues for Referral

Pearls and Pitfalls ⬆ ⬇

Additional Reading ⬆ ⬇

Codes ⬆