CRYING CHILD –PRACTICAL APPROACH

DR M R BHALERAODNB (PED)CONSULTANT PEDIATRICIAN,OLD SANGVI,PUNE 411027

Babies cry because they cannot Talk !

Crying is Baby Communication !

INTRODUCTION

Most common complaint , for which the child is brought to Pediatrician/ Primary Physician

Lot many reasons why child cry ! Prevalence of excessive crying 1.5 – 40 %

UK study annual cost of 108 million dollars spent by NHS on care of infants with crying & difficulty in sleeping in 1st 12 wks alone

INTRODUCTION

We have to differentiate when the cry is an abnormal & find out the reason behind it

Each case should be looked as a clinical challenge rather than as annoyance

Fear of missing a diagnosis may result in unnecessary & invasive tests

Introduction Crying is an important cause of maternal anxiety & stress, strongly

associated with maternal depression.

Can affect breast feeding

Stress in relationships – mother-infant , mother- family members , mother – father relationship

Can be associated rarely with physical violence

How much crying is normal ? Brazelton ( 1962)-studied babies from birth -

12wks

Infants in their 2nd wk of life cried & fussed for median 1.75 hrs, which increased to a peak median of 2.75 hrs at 6 wks, after which there was decline in the amount of crying

There appears circadian pattern , concentrated most in late afternoon and evening.

Colic in infants Illingworth (1954 )- described 50 infants <

3months with’ rhythmic attacks of screaming’ ,without any inciting cause & labeled them as “ Three months colic”

Wessel et al used the term “ paroxysmal fussing “ .

Amount of crying that is considered excessive is accepted from Wessel’s studies (>3 hrs)

Acute crying –role of a physician (1) to avoid missing a serious or life-

threatening aetiology & (2) to determine the common/treatable

diagnoses . In their study of 200 crying infants who

presented to the ED, Fahimi et al found that the 3 most common diagnoses were colic (29.5%), acute otitis media (15.5%), and constipation (5.5%)

Non pathological causes

Hunger, thirst, tiredness ,discomfort

Separation from mother

Temperature disturbances in the environment

Need to clean up

Pathological causes of crying Most of the diseases of neonates,

infants and children have irritability as a major manifestation.

For pediatrician it is important to decide the cause of irritability/crying, though difficult at times

Crying …. Complaint of crying is so nonspecific,

differential diagnosis is so extensive,

THOROUGH HISTORY , CLINICAL EXAMINATION

TOP UP WITH

YOUR CLINICAL EXPERIENCE !!!

Assessment of the baby parental concern was “red flag” in identifying

serious illness, with a positive likelihood ratio (LR) of 14.4 (95% confidence interval [CI] 9.3-22.1 (Van den Bruel et al )

Clinician’s concern : “gut feeling” that something was wrong, despite the assessment, substantially increased the likelihood of serious illness with a LR of 25.5 (95% CI, 7.9-82)

history as diagnostic in 20% to 86% of cases, alone

or in conjunction with physical examination findings

Studies ( Poole et al ) Poole et al- emergency department visits

with ages ranging 4 days- 24 months-

61 % had diagnosis that was serious illness, of those history provided clues in 20 %

physical examination provided Dx in 41%

& clues leading to Dx in 13%, remaining 24% continued to cry after initial assessment

Systematic approach to crying patient Examine patient from head to toe literally

!!

General examination: temperature, pulse, respiration ( vitals ), hydration of the baby

Examination of head: anterior fontanel (boggy/ depressed )

prominent veins over scalp sutural separation

Examination

Ears : otoscopy ( AOM/ MEE) discharge from ears foreign body

Nose : sinusitis bloody discharge ( foreign body )

Throat : vesicles (herpangina ) pooling of secretions

( parapharyngeal abscess)

Acute otitis media

Herpangina

Oral candidiasis

Examination

Eyes : foreign body ,injury, intraocular pressure ( corneal enlargement in glaucoma)

Neck : e/o swelling , abscess, LN suppuration

Mouth : apthous ulcers, oral candidiasis, stomatitis

EXAMINE EYES FOR – FB, INJURY, CLOUDY CORNEA ETC

Examination

Respiratory system : tachypnea , crepts/ bronchial breathing , e/o foreign body

Per Abdomen : mass / lump in abdomen (intusseption ) , P/R exam if required Don’t forget to undress the child -- impacted inguinal hernia, torsion of testis may be missed

Torsion right testis Impacted lt inguinal hernia

INTUSUSEPTION

Musculoskeletal system exam Examine all bones and joints

carefully to exclude fractures

joints for e/o septic arthritis , transient synovitis

look for pseudo -paralysis as in Scurvy

SCURVY XRAY

Examination

CNS : most important to r/o Intracranial infection

Examine for toxicity, see neuro behavior of the child, feeding history ,convulsions, focal neurological signs.

Genitourinary system : dysuria, perivulval/perianal redness , labial synaechiae

Labial synaechiae ( before separation)

Labial synaechiae ( after separation)

Summary of causes

Head & eyes : 1. trauma

2. corneal abrasion

3. ocular/nasal/ear foreign body

4. glaucoma

5. panniculitis

Summary of causes Respiratory system :

UR system – blocked nose acute otitis media foreign bodies

LR system – bronchiolitis pneumonia foreign bodies pneumothorax

Summary of causes

Cardiovascular : 1. congestive heart failure

2. supraventricular tachycardia

3. endocarditis , myocarditis

4. myocardial infarction

Summary of causes Gastrointestinal & genitourinary system : colic ( evening colic, colic associated with

AGE, dysentery etc)

Intusseption ,bowel obstruction, volvulus colitis , appendicitis

Impacted feces / constipation GERD , esophagitis anal fissure, hemorrhoids

Summary of causes

Gastrointestinal & genitourinary system(cont.):

milk protein allergy incarcerated inguinal hernia testicular torsion Urinary retention, urinary tract

infection balanitis / balanopsthitis

Summary of causes

Musculoskeletal system :

fracture osteomyelitis arthritis vaso-occlusive crisis ( sickle cell

anemia ) dactylitis

Summary of causes Central nervous system :

meningitis / encephalitis

intoxication , neonatal drug withdrawal

causes of raised ICP ( hydrocephalus, mass , ICH, cerebral edema

pseudotumour cerebrii

Summary of causes

Dermatologic : burns

Cellulitis

insect bites / urticaria

atopic dermatitis / mastocytosis

Summary of causes Miscellaneous causes :

drug overdoses ( nalidixic acid, Vitamin A etc)

post vaccination ( DPwT) recovery from neurological diseases

Scurvy

treatment 1) Infants with clear diagnosis/

identifiable cause

(2) infants who continue to cry without a clear, identifiable cause

---outpatient follow up visit within 24 hours----avoidance of medicating unknown / unclear

diagnosis--- reassurance and supportive measures to

the parents

Considering special situations Consider common diagnosis first

Rule out serious underlying disorders

Colic has historically been defined as paroxysms of excessive crying lasting > 3 hours per day, occurring > 3 days in any week for 3 weeks, in an otherwise healthy baby aged 2 weeks to 4 months. It is estimated to affect 10% to 30% of infants worldwide.

Causes of colic

Proposed causes include: cow’s milk protein allergy or

intolerance, gastrointestinal reflux disease,

feeding difficulties, sleep difficulties,

and neurodevelopmental immaturity

Baby parent interaction

Time & cost effective strategies Don’t initiate extensive & expensive work

up on every crying patient

May not be possible to identify the correct etiology during Emergency visit , can arrange follow up visit

Don’t forget urine analysis

For Crying Infants Criteria For Admission

Toxic-appearing Hemodynamically unstable , critical illnessClinically stable with a condition requiring IV therapy (fluids, antibiotics)

No access to immediate follow-up care Ongoing crying without a clear-cut etiology after examination, observation, and appropriate testing

Social concerns (poor support at home, unsafe environment for the infant, risk factors for abuse or neglect)

Admission criteria for crying babies

1.Well-appearing/consoled Clinically stable with a condition treatable in outpatient therapy (oral antibiotics, analgesics)

2.Access to immediate follow-up care Resolution of crying in the ED or ongoing crying that is baseline or not concerning to provider or caregiver

3.No social concerns Parents are comfortable with discharge plan and understand next steps regarding treatment and follow-up

.

Criteria for discharge from ED

Excuses / myths during assessment

“The baby did not have a fever, so I did not consider that he could have a serious infection

“Of course the baby had an elevated heart rate; he was crying

The parents seem really nice, so there is no need to consider nonaccidental trauma.”

Excuses during assesment “All babies cry. This is a normal finding and

is nothing to worry about.” ( thik ho jayega) “The more tests I perform, the closer I will be to

making a diagnosis

“This baby just has colic”

“Parents are always anxious about their babies, but it doesn’t mean anything is truly wrong with the infant.”

Carry home messages History and clinical examination …the most

important tools

No universally recommended lab tests/ imaging studies….. Individualize the decisions

Colic & unexplained crying are the most common, than underlying serious pathologies

Don’t miss underlying serious disorder

Summary – ’ IT CRIES’ I – Infections ( herpes stomatitis, UTI,

meningitis, osteomyelitis & so forth )T – Trauma ( accidental/non accidental ),

testicular torsionC - Cardiac ( congestive cardiac failure, SVT

)R – Reflux, reaction to medications/formulas I – Immunizations, insect bitesE – Eye ( corneal abrasions, FB, glaucoma)S – Surgical ( volvulus,intusseption, hernia)

GOOD NIGHT & HAVE SWEET DREAMS !

Infantile colic

Infantile colic

Behavioral state, characterized by unexplained paroxysms of inconsolable crying , lasting for more than 3 hrs a day & occurring more than 3 days in a week, for a period of 3 weeks .

Occurs in 10-25% of infants

Onset is usually 2-3 wks of age , peaking at 6-8 wks and remitting at 3-4 months of age

Infantile colic ( cont.)

Episodes usually occurs during evening hours

Infant may grimace, pass flatus , clench his/her fists and draw up his/her legs

Cry is prolonged ,loud, high pitched – described as piercing

Infantile colic-- causes

Colic is a diagnosis of exclusion

Exact cause of colic not known , many possibilities thought of—

Gastrointestinal causes Neuropsychological causes Food allergies parental misadventures

Infantile colic --causes

a) carbohydrate malabsorption

b) lactose in the diet, CMPA

c) increased gas in the infants with colic ??

d) behavioral factors such as feeding abnormalities ,infant positioning while feeding

e) Psychological factors suggested possible etiologies like underdeveloped parenting skills, parental anxiety, stress

For diagnosis of colic, routinely lab investigations are not required, unless you suspect something else

Factors aggravating colic Overfeeding in an attempt to lessen

crying

Feeding certain foods ,especially those with sugar content , may increase amount of gas in the intestines ( e.g. undiluted fruit juices )

Presence of excessive anger, fear, excitement in household

Multiple factors as yet unknown

Treatment of infantile colic Reassuring the parents that colic is self-

limited. Encourage parental rest breaks, developing strategies for crying episodes

Folk remedies ( herbal teas- licorice, dill oil,fennel oil ) ?? Efficacy

Behavioral modifications-positioning of infant during feeding, early response to crying –shown not to be effective

Treatment of infantile colic--cont Medications targeting GI system

( simethicone Vs placebo- demonstrated equal improvement)

Dicyclomine has shown effect in some RCTs, but issues of safety ( apnea ,other serious adv effects) . Not recommended < 6 mths

? Changing formulas , ? Lactose free formulas ,addition of lactase in formula–No benefit

Low allergen diet in mother ( diet free of egg, milk, nuts, wheat, artificial colors & preservatives ).

Herbal remedies ( tea containing chamomile, vervain, licorice, fennel etc) showed some reduction in crying.

Summary And

Conclusions

Summary – ’ IT CRIES’ I – Infections ( herpes stomatitis, UTI,

meningitis, osteomyelitis & so forth )T – Trauma ( accidental/non accidental ),

testicular torsionC - Cardiac ( congestive cardiac failure, SVT

)R – Reflux, reaction to medications/formulas I – Immunizations, insect bitesE – Eye ( corneal abrasions, FB, glaucoma)S – Surgical ( volvulus,intusseption, hernia)

Conclusions

Common clinical dilemma Every case has to be individualised History & clinical examination are main

tools Ordering unnecessary test add stress to

family & cost burden ! Sick child, poor growth ,inconsolable

child deserves investgations Don’t forget possibility of abuse Support, reassuarance needed in many

IF A CHILD DOESN’T CRY ……………. …………………. ………………… …………………. ……………………..

…………………………

PEDIATRICIAN MIGHT!!!

THANKING ALL OF YOU FOR MAKING ME SMILE!!!