You hear a piercing shriek reverberate across your emergency department. The tracking board shows a chief complaint of “crying.”

What Is Normal?

Medical professionals and laypeople understand that infants cry as a primary means of communication. However, the first challenge when assessing a crying infant is determining what crying is defined as normal. The definition of normal crying originates from a 1962 article by T. Berry Brazelton, who determined that the median hours an infant spends crying is 1.75 hours a day at two weeks of age, peaks at 2.75 hours a day at six weeks of age, and decreases to less than one hour of crying a day by 12 weeks.¹ As a medical provider, it is important to seriously consider the concerns of any caregiver who has noticed an acute change in the crying patterns of a child.

The physician should determine the onset, duration, frequency, and aggravating and alleviating factors of the crying and any of its associated factors. Distinctive aspects of the infant’s past medical history should be recorded, including birth history and the maternal history of prescription drug use, illicit drug use, alcohol use, and smoking. The infant’s stool frequency and consistency should be determined. Caregivers should also be screened for their response to the crying, their social support, and fatigue.² Such factors may be associated with abuse.

A full set of vital signs should be obtained, including weight, for the evaluation of appropriate growth. Time should be taken to perform a comprehensive head-to-toe examination. The exam should include the palpation of the fontanelles and skull for fullness and hematomas. The mental status of the infant should be assessed by determining whether the infant is alert; hypoglycemia should be considered early with a depressed mental status.

The provider should consider conducting an ocular exam, including fluorescein stain and eyelid eversion to look for foreign bodies, as well as an ear exam to look for acute otitis media and foreign bodies. A tongue depressor should be used to study the infant’s oropharynx for ulcers or lacerations. Long bones and joints, including clavicles and ribs, should be examined. The chest cavity should be assessed for abnormal cardiac or lung sounds. An abdominal exam should include inspection, auscultation, and palpation. The skin should be thoroughly investigated for signs of injury, rash, or a hair tourniquet. The testicles should be evaluated for hernias, anal fissures, and signs of trauma.³ The “IT CRIES” mnemonic (see Table 1) can be helpful in conducting the initial differential diagnosis of a crying child.

Table 1. IT CRIES Mnemonic for Initial Differential Diagnosis of a Crying Child

Source: Adapted from Emerg Med Clin North Am. 2007;25(4):1137-1159.

Considering Colic

Excessive crying does not necessarily equate to an infant having colic. Rather, colic is defined as an otherwise healthy infant who meets the rule of threes: crying more than three hours per day more than three days per week for more than three weeks in duration.⁴ Classically, colic begins at two weeks of age, peaks at six weeks, and resolves between 12 and 16 weeks.⁵ The term “colic” focuses on the frequency of crying that is difficult to console and is not specific to other factors.

Evaluation and Disposition

Determining the medical history and performing a physical examination remain the cornerstones for the evaluation of a crying infant and should drive investigation selection. Routine fluorescein examination is controversial. Resolution of crying with topical anesthetics may be more diagnostic for an adult with a corneal abrasion. However, identifying a corneal abrasion alone could lead to premature diagnostic closure. In one study, corneal abrasions were identified in almost half of the young infants at well-child checks.⁶ Useful tests for the otherwise clinically well child may be urinalysis and culture. In one study, 5 percent of 237 children presenting with crying were found to have a urinary tract infection, the most prevalent condition.⁷ Other investigations should be performed based on clinical findings.

One of the most powerful diagnostic tools a physician has is observation. Many children with reassuring medical histories and physical exams need to be observed in the emergency department. The care team can evaluate how an infant behaves between crying episodes and work with caregivers on techniques to comfort the child. A medical team can also evaluate whether a child is improving, worsening, or staying the same as well as how caregivers are interacting with the child. Parental reassurance and behavioral interventions, such as swaddling, low-level background noise, massage, rocking, bouncing, or having someone else care for the child briefly, are the predominant interventions in the emergency department. Remember that children who are difficult to console are at risk for child abuse. No evidence-based medical interventions exist for a crying infant.² Simethicone is often recommended as a pharmacologic intervention but was found to be no more effective than a placebo in one randomized control trial.⁸ Dicyclomine has been shown to cause apnea and seizures.⁹

It is safe to discharge most children home with strict return precautions. Follow-up within 24 hours should be encouraged. Teaching good supportive measures, such as regular and full feedings, diaper care, temperature regulation, consistency of care, and ways for caregivers to obtain social support, are imperative.²

References

1. Brazelton TB. Crying in infancy. Pediatrics. 1962;29(4):579-588.
2. Chua C, Setlik J, Niklas V. Emergency department triage of the “incessantly crying” baby. Pediatr Ann. 2016;45(11):e394-e398.
3. Herman M, Le A. The crying infant. Emerg Med Clin North Am. 2007;25(4):1137-1159.
4. WesselMA, Cobb JC, Jackson EB, et al. Paroxysmal fussing in infancy, sometimes called colic. Pediatrics. 1954;14(5):421-
5. Cohen GM, Albertini LW. Colic. Pediatr Rev. 2012;33(7):332-333.
6. Shope TR, Rieg TS, Kathiria NN. Corneal abrasions in young infants. Pediatrics. 2010;125(3):e565-569.
7. Freedman SB, Al-Harthy N, Thull-Freedman J. The crying infant: diagnostic testing and frequency of serious underlying disease. Pediatrics. 2009;123(3):841-848.
8. Metcalf TJ, Irons TG, Sher LD, et al. Simethicone in the treatment of infant colic: a randomized, placebo-controlled, multicenter trial. Pediatrics. 1994;94(1):29-34.
9. Savino F, Tarasco V. New treatments for infant colic. Curr Opin Pediatr. 2010;22(6):791-797.

Dr. Witkov is a PGY2 emergency medicine resident at McGovern Medical School in Houston.

Dr. Kosoko is an assistant professor of emergency medicine at McGovern Medical School at the University of Texas Health Science Center in Houston.