The Crying Infant
Colic

General

•  def’n: less than 1 yo and CAREGIVER says that patient is crying excessively

•  most infants w/ excessive crying or irritability do not have significant pathology

•  most infants without serious conditions stop crying excessively after their evaluation

• abnormal physical findings or persistent crying beyond the initial assessment may be predictive of serious illness, with 100% sensitivity (95% CI 90-100%), 77% specificity (95% CI: 54 to 91%) and PPV 87% (72-95%)

• In infants younger than 4 months of age, the most likely dx is normal infant with above average crying or infantile Colic(especially if this is not the first episode)

• Explore feeding (over/underfeeding), teething and parental stress, the need for additional support. Follow up within 24 hours!

Workup

• ABC’s

•  Careful H&P: every part of body should be examined with garments removed

• KEEP IN MIND -> DO NOT MISS:

• Close Physical Exam: Corneal abrasion (fluorescein exam), Tourniquet syndromes, Foreign body, Physical abuse (retinoscopy), Serious infectious illness

• Surgical: Acute surgical abdomen, Incarcerated hernia, Intussuception, Testicular torsion

• Cardiac: Anomalous coronary artery, Congestive heart failure

• Labs: Electrolyte disturbances, Serious infectious illness

• RED FLAGS: abnormal level of consciousness, abnormal vital signs, evidence of trauma or anemia, vomiting, diarrhea, ehmatochezia and abdominal tenderness or distension, signs of tourniquet syndrome, eye tearing, photophobia or conjunctival irritation, growth abnormality (incl head circ), and signs of cardiorespiratory compromise.

• If PE is normal

•  Look at consolability: very few consolable infants have a serious condition. Look into nonurgent causes of crying:

•  Colic, constipation, feeding problems, parenting difficulties, teething, vaccine reaction, viral syndrome

• AND monitor at 24 hour (or less) intervals for development of a serious illness

• In a patient with a normal PE, is consolable, and has a hx c/w infantile Colic, laboratory tests are usually not required.

• 60% of inconsolable patients have a serious illness

• an unconsolable infant should be observed in the hospital until a diagnosis can be established. LAB studies are necessary.

• Consider:

• CBC, ESR or CRP (infection or inflammation)

•  Lumbar puncture (meningitis or encephalitis)

•  Hb electrophoresis (SS dz)

• Electrolytes, serum pH (electrolyte abnormalities, metabolic disease)

• U/A and culture (pyelonephritis)

• Stool guiaic (intussuception, gastroenteritis, cow’s milk allergy)

• Skeletal survey, bone scan (abuse)

• Head CT (intracranial hemorrhage, hydrocephalus)

• Amino and organic acid studies (metabolic abnormality)

Reference:

Kliegman. Practical Strategies in Pediatric Diagnosis and Therapy