Crying and fussing in infants

Probability diagnosis

Normal/hunger

Infantile ‘colic’

Teething

Viral URTI/illness

Otitis media

Constipation

Serious disorders not to be missed

Vascular:

• Cardiac failure

Infection:

• Meningitis/encephalitis

• Gastroenteritis

• Other systemic infection

Other:

• Gastro-oesophageal reflux/oesophagitis

• Injury esp. non-accidental, birthing

Pitfalls (often missed)

Severe nappy rash

Constipation

Cow’s milk intolerance

Lactose intolerance

Balanitis (males)

Rarities:

• Bowel obstruction/pyloric stenosis

• Intussusception

• Other congenital e.g. oesophageal atresia

Masquerades checklist

Urinary tract infection

Is the patient trying to tell me something?

?hunger ?soiled napkin ?tiredness ?family dysfunction ?inattention

Key history

Obtain detailed account from parents of the crying pattern and duration, as well as the circumstances of discomfort incl. feeding, time relationship to feeds and associations, particularly vomiting or possetting, presumed abdominal discomfort, constipation, bowel actions and fever. Establish if breastfeeding or providing other milk and food. Ask about recent immunisation.

Key examination

• General features: appearance of the child, growth parameters and vital signs

• Abdominal examination esp. inspection, palpation and auscultation

• Examine skin looking for evidence of eczema and napkin rash

• Examine the ears, fontanelles

• Also assess the child’s temperament and coping abilities

Key investigations

Nil for most cases

Consider:

• urinalysis

• MCU

• FBE

• ESR/CRP

• stool analysis

• referral for upper GIT investigation

Diagnostic tips

The normal pattern is for crying to start increasing around 2 weeks of age, to peak around 2 months and then settle down 3–4 months of age.