- Oct 23rd, 2015
- Sean M. Fox
Originally published at Pediatric EM Morsels on June 26, 2015. Reposted with permission.
Follow Dr. Sean M. Fox on twitter @PedEMMorsels
Without question, one of the most challenging tasks in life is to raise a child. The degree of difficulty of this challenge is heightened when that child becomes “inconsolable.” Since a young infant or child has a limited repertoire to convey illness, constant crying needs to be taken seriously by us in the Emergency Department. So, before you jump to the conclusion that this is merely “Colic” in the 2 month old, let us quickly highlight some entities that should be at the top of your DDx when evaluating the inconsolable child.
Inconsolable Child: A Mnemonic May Help
- Personally, I have a difficult time remembering Mnemonics, but this one can be helpful.
- IT CRIES
- I = Infections (ex, UTI, Meningitis, Sepsis)
- T = Trauma (ex, Subdural Hematoma, Fractures, Non-accidental trauma)
- C = Cardiac Disease (ex, SVT)
- R = Reaction to meds, Reflux, Rectal/Anal Fissure
- I = Intussusception
- E = Eyes (ex, corneal abrasion, foreign body, glaucoma)
- S = Strangulation, Surgical Processes (ex, Hernia, Testicular/Ovarian Torsion)
Inconsolable Child: Head to Toe Exam is Key!
- Neuro exam – change in MS? Hypoglycemia??
- Full fontanelle – space-occupying lesion? Infection?
- Hematoma or Ecchymosis – Trauma?
- Corneal abrasion? Little kids often have talons for fingernails. [Harkness, 1989]
- Eversion of eyelid for retained FB
- Red eye and excessive tearing? Congenital conjunctivitis? Glaucoma?
- Acute Otitis Media
- Retained FB
- Strawberry tongue? (Kawasakai Disease?)
- Rib fractures
- Dysrhythmia (ex, SVT)
- Congenital heart disease
- Bowel Perforation
- Hirschsprung Disease
- Diaper Region
- Testicular/Ovarian torsion
- Incarcerated hernia
- Hair Tourniquet
- Anal fissure
- Hair tourniquet
- Sickle cell disease
- Septic joint
- Post-vaccination (ex, DPT)
- Petechiae, purpura, etc.
Inconsolable Child: But, What About Colic?
- Colic is certainly a possibility… but, it is a diagnosis of exclusion!
- Colic also has some criteria… so not all crying is colic!
- 10-26% of infants experience colic
- Excessive crying for:
- >3 hrs per day,
- >3 days per week,
- >3 weeks in duration
- Can begin as early as 2nd week of life
- Peaks around 6th week of life
- Should resolve by 16th week of life.
Moral of the Morsel
- A thorough history and physical exam will be the best tool to help you determine the cause of the crying. [Freedman, 2009]
- Be diligent: pry open the mouth, look in the diaper area, exam each appendage (large and small).
- Don’t be in a hurry to diagnose colic!
Cohen GM1, Albertini LW. Colic. Pediatr Rev. 2012 Jul;33(7):332-3; discussion 333. PMID: 22753793. [PubMed] [Read by QxMD]
Freedman SB1, Al-Harthy N, Thull-Freedman J. The crying infant: diagnostic testing and frequency of serious underlying disease. Pediatrics. 2009 Mar;123(3):841-8. PMID:19255012. [PubMed] [Read by QxMD]
Herman M1, Le A. The crying infant. Emerg Med Clin North Am. 2007 Nov;25(4):1137-59, vii. PMID: 17950139. [PubMed] [Read by QxMD]
Poole SR1. The infant with acute, unexplained, excessive crying. Pediatrics. 1991 Sep;88(3):450-5. PMID: 1881722. [PubMed] [Read by QxMD]
Harkness MJ1. Corneal abrasion in infancy as a cause of inconsolable crying. Pediatr Emerg Care. 1989 Dec;5(4):242-4. PMID: 2602200. [PubMed] [Read by QxMD]