Why Will This Baby Not Stop Crying?

Image Credit: Flickr, Photo by Tatiana Vdb

Author: Josh Bowers, DO
Emergency Medicine Resident
Adena Regional Medical Center

This post was peer reviewed.
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It is 3:00 am and a mother brings in her crying infant. The mother seems to be at a loss and states:

“Nothing I do will make him stop crying.”

The crying infant is a common complaint of parents [1,2,3] and a difficult diagnostic problem for emergency physicians. The etiology of an infant’s crying can range from normal patterns of infant crying to life threatening conditions. As emergency physicians, it is our job to differentiate between the benign and not-so-benign reasons for persistent crying and treat accordingly. Not only is it tough to take care of a patient that cannot verbalize their complaint, but it is even more challenging when you have had no previous interaction with the patient. [2]

Luckily there are a few good clues that can help you avoid missing a serious etiology and determine the common/treatable diagnoses.

First, keep in mind that heightened parental concern has been found to be a “red flag” in identifying serious illness; it has a positive likelihood ratio (LR) of 14.4.[1] Second, any concern that you have as a clinician is also considered a strong “red flag” for serious illness with a positive likelihood ratio of 23.5.[1] Third, excessive crying in the ED beyond the time of assessment was predictive of serious illness (sensitivity 100%, specificity 77%).[2] (Sidenote on likelihood ratios: LR greater than 1 indicates an increased probability the target disorder is present. A LR greater than 10 offers a large and often conclusive increase in the likelihood of disease.[6])

The importance of taking a thorough history cannot be understated; the history is diagnostic between 20-80% of the time.[3,4] While this is a wide range, maintaining thoroughness during your history will undoubtedly assure the parents that their concerns are heard. Once you have evaluated the ABC’s and have your history, pay particular attention to the physical exam.[2] Get them naked and check everything out. This is important because it can contribute to diagnoses in >50% of cases.[3,4]

The following list delineates areas which should be given particular attention and the differential diagnoses which should cross your mind. [1,2,3,4,5]

• Head and neck
• Corneal abrasions
• Acute otitis media
• Non-accidental trauma
• Oropharyngeal pathologies
• Thorax
• Clavicular fractures
• Vertebral osteomyelitis and discitis
• Rib fractures
• Mastitis
• Heart and cardiovascular system
• Arrhythmias
• Congenital heart disease and heart failure
• Abdomen
• Constipation
• Hirschsprung disease
• Pyloric stenosis
• Malrotation with volvulus
• Intussusception
• Genitourinary system
• Occult urinary tract infection
• Inguinal hernias
• Hair tourniquet
• Extremities
• Septic arthritis
• Fractures
• Hair tourniquet
• Nervous system
• Hypoglycemia/nervous irritability
• Central nervous system infections
• Occult head injury
• Skin
• Ecchymosis
• Burn 

With a good knowledge base and careful planning, you will not miss the life-threatening diagnoses. However, not all persistent crying is life threatening or easy to treat. Emergency physicians often have to provide reassurance, education, empowerment, and resources (including follow-up) to the parents of these crying infants.[4]

Financial Disclosures: None.

References:

1. Van den bruel A, Haj-hassan T, Thompson M, Buntinx F, Mant D. Diagnostic value of clinical features at presentation to identify serious infection in children in developed countries: a systematic review. Lancet. 2010;375(9717):834-45.

2. 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):1-17.

3. Poole SR. The infant with acute, unexplained, excessive crying. Pediatrics. 1991;88(3):450-5.

4. Freedman SB, Al-harthy N, Thull-freedman J. The crying infant: diagnostic testing and frequency of serious underlying disease. Pediatrics. 2009;123(3):841-8.

5. Trocinski DR, Pearigen PD. The crying infant. Emerg Med Clin North Am. 1998;16(4):895-910, vii-viii.

6. McGee S. Simplifying Likelihood Ratios. J Gen Intern Med. 2002;17(8):647-650