CRYING CHILD
Dr. (Prof.) S. A. Krishna*, Dr. R. K. Murmu**
M.D.; F.I.A.P.; F.I.A.M.S. Head of Department, Dept. of Pediatrics DMCH, Lehariasarai. *, M.D. (Ped) Patna. **
Keywords
Crying baby, crying child, irritable child, irritable baby, inconsolable baby
Introduction
One of the most challenging aspects of pediatric medicine is dealing with a child (usually < 2 year) presenting with non-specific symptoms, such as crying and irritability.

Due to the child's inability to localize complaints, these symptoms can indicate a spectrum of diseases ranging from a benign process, such as colic, to a life-threatening illness, such as meningitis.

A baby's cry is distressing for parents and it is meant to be. It is the baby's main way of letting people know that something is not right and that he needs help. A new baby cannot care for himself, and has to call for help. The challenge is to work out what the baby needs and what will stop the crying. This is not always easy and babies may cry quite a lot in the early weeks, even when their parents are very attentive.

Constant or prolonged crying is most tiring for the mother and thus becomes a potent cause of child abuse.

Normal crying patterns:
  • There is a wide range of normal crying. Some babies cry much more than other babies for no clear reason.
  • Studies show babies fuss or cry about two hours a day on an average, some rather more and some less.
  • Young babies may have one or two times each day when they usually cry, with some unsettled behavior in between. The late afternoon and evening tend to be the worst.
  • The amount of crying often increases until the baby is about 6 weeks old, and then tends to settle a lot after 3 months. This is not the same for all babies.
  • Parents often feel their baby cries more than other babies, or more than they expected.
Causes: Causes of crying and irritability in the young child can vary greatly from relatively benign conditions, such as colic to life-threatening conditions, such as meningitis.

The most common causes of crying in the newborn period are discomfort and loneliness. The chief cause of discomfort is hunger. On a self-demand schedule crying is quickly checked by a feed, provided that the quantity of food is adequate. Some will not brook a moment's delay when they are hungry and scream so vigorously that the babies are well suited by a rigid feeding schedule because the time laid down for their feed happen to coincide with their needs.

Crying from hunger may be due to fixed ideas of the duration of feeds or of the quantity, which a child should take. Babies are individuals and some suck better and more quickly than others. Rigid rules for the duration and quantity of feeds should not be laid down because they cause so much unnecessary crying.

An important cause of crying in young babies is thirst due to the feed of cows' milk, formula being made up too strong, or to excess of salt in tinned pureed foods, or even to excess of salt in breast milk.
Another cause of discomfort in the newborn period is wind during first 3 months, which causes colic. It occurs mostly, but not entirely, in the evenings.

Other causes of crying are over-clothing, excessive heat or cold, a wet or soiled nappy, and itching rash or an unpleasant smell or taste such as that of vomit. A baby may cry when there is a sudden noise or when a light shines on his face. Sometimes the newborn baby cries when the light is put out and he finds himself in the dark.

Crying in the newborn period may be due to loneliness. The crying stops as soon as he is picked up, whereas the crying of hunger does not stop, or else there is a minute's quiet and then he cries again even though he is in his mothers' arms.

Crying commonly occurs when the position is suddenly changed, particularly if the baby is allowed suddenly to fall back from the sitting position.

After 5 to 6 months, fears may cause crying. The baby may cry when he sees a strange face. The development of ego and personality leads to crying from 6 months onwards. Even at 5 months the baby may show striking likes and dislikes and cry when given food which he does not like, or when fed from a cup or dish which is not the usual one. A determined independent child at 6 or 7 months may refuse to take food unless he is allowed to help to hold the spoon.

From 9 months onwards the baby may show signs of jealously and cry when he sees his mother pick up another baby.

Excessive crying in this period is almost always due to failure to answer the child's basic needs for comfort, love, security, and for opportunities to practice his newfound skills.

After the first birthday there is a further reduction in frequency of crying. Crying is liable to be the result of conflict with the developing ego and with his newly found interest.

The following is a partial listing of potential pathological causes of crying and irritability.
  • Infections:
    • Meningitis
    • Urinary tract infections

    • Appendicitis
    • Pneumonias
    • Sepsis

    • Otitis Media
    • Gastroenteritis
    • Local skin infections
  • Trauma
    • Corneal abrasions
    • Strangulation of extremities or genitalia (by hair)
    • Fractures

    • Abuse (including shaken baby syndrome)
    • Burns
    • Subdural hematomas
    • Foreign bodies
  • Dental/oral

    • Aphthous ulcers
    • Dental eruptions (with or without pericoronitis)
  • Toxic or metabolic causes of irritability include any transient or persistent change in body chemistries.

    • These can be endogenous or exogenous in origin.

    • Toxic exposures (e.g., cocaine) and metabolic and electrolyte abnormalities (e.g., hypoglycemia, hypocalcemia, hyponatremia) are among a few of the potential causes.
  • Genitourinary concerns include testicular torsion, hernias, and urinary tract infections.

  • GI causes include life-threatening conditions (e.g., intussusception, gastroenteritis) to more self-limiting conditions (e.g., fissures, formula intolerance, colic).

  • Cardiovascular concerns include supraventricular tachycardia or other arrhythmias.
Other causes of crying and irritability are possible; however, a good system-by-system history and physical examination should help identify or rule out most concerns.
Clinical Examination
History:
  • The child's past medical history, including surgeries, hospitalizations, illnesses, pregnancy complications, allergies, and
  • Birth events should be obtained.
  • Present medicines and recent illnesses should be reviewed.
  • An explanation of events, including feeding habits, bowel movements, urination, fever, sick contacts, level of activity,
  • degree, and duration of concerns and ability to be consoled should be obtained.
Physical:
  • A complete and thorough physical examination should include the following: overall appearance, ability to be consoled, stability of vital signs and temperature of the child.
  • Other important aspects:
    • Skin rashes, perfusion, or bruising.
    • Head, ears, eyes, nose, and throat, examination for anterior fontanel fullness, hydration status, sclera color, corneal
    • abrasions, pupillary activity, retinal hemorrhages, otitis, pharyngitis, foreign bodies or neck tenderness.
    • Dental examination for new tooth eruptions, caries.
    • Chest evaluation for breath sounds and tachypnea.
    • Cardiovascular examination for murmurs, tachycardia or arrhythmias.
    • Abdominal evaluation for tenderness and bowel activity, left lower quadrant masses suggestive of constipation, or vertical
    • sausage mass consistent with intussusception.
    • Genitourinary examination for hernia, torsion or strangulations by hair tourniquets.
    • Rectal examination for blood or fissures.
    • Evaluation of extremities for focal tenderness, arthritis or hair tourniquets.
    • Neurological evaluation for overall activity level, responsiveness and ability to be consoled.
Laboratory Studies:
  • The history and physical examination should direct lab studies.
  • In contrast, alarming items in the history and/or physical examination may make rapid diagnostic workup and treatment necessary.

    • Children with fever, temperature instability, lethargy, or inconsolability should have an age-appropriate workup for sepsis.
    • At a minimum, this includes a complete blood count (CBC), serum electrolytes, blood culture, urinalysis, and urine culture.
    • Also consider a lumbar puncture if younger than 2 months or if directed by examination, and a chest x-ray if respiratory symptoms exist.
    • Because children with urinary tract infections and gastrointestinal pathology may appear intermittently well, a urinalysis and stool guaiac test should be considered even if the child is afebrile and clinically stable.
    • If abuse or head trauma is suspected, a CT scan of the head and long bone x-rays should be considered.
  • Children at risk for corneal abrasions, such as those with untrimmed nails or scratches on the face, should have an eye examination with fluorescein staining.
  • An ECG should be obtained if there is any question of cardiac instability.
  • An abdominal ultrasound and/or barium enema is necessary in suspected cases of intussusception.
  • A toxicology screen should be performed if acute or chronic exposures are thought to exist.
Treatment
HOME CARE ADVICE FOR MILD, CONSOLABLE CRYING
  1. Reassurance: Most infants/toddlers become somewhat irritable and fussy when sick or overtired. Crying tells us that child is not feeling well. If the crying responds to comforting, it's probably not serious.

  2. Comforting: Try to comfort child by holding, rocking, massage, etc.
  3. Sleep: If child is tired, put him to bed. If he needs to be held, hold him quietly in a horizontal position or lie next to him. Some overtired infants need to cry themselves to sleep.
  4. Undress your Child: Sometimes part of the clothing is too tight or uncomfortable. Also check the skin for redness of swelling (e.g., insect bite).
  5. Expected Course: Most fussiness with illnesses resolves when the illness does. Most fussiness due to stress or change (e.g., new day care) lasts less than 1 week.
  6. Consult Doctor if:

    • Constant crying lasts for more than 2 hours.
    • Intermittent crying lasts more than 2 days.

Settling ideas: Crying babies tend to arch their heads back and stiffen their legs. Holding them into a C or flexed position can help them calm down.
  • Wrapping or swaddling in a cotton sheet can be calming and help the baby sleep for longer.

  • Baby slings are great to provide the comfort and contact that babies need when you have something else to do.
  • Soft music, rhythmic sounds, or continuous machine noises (such as the noise made by a washing machine) soothe some babies.
  • Most babies' settle when taken for a walk in the pram, and the exercise helps parents feel better too. Don't leave baby sleeping unattended in a pram, though.
  • Some babies only seem to settle when taken for a drive. This is not ideal, but if you are able to do this safely (i.e., you are not too tired, or too distressed by your baby's crying) this might be useful for the few weeks before he grows past this stage.
  • Whispering to babies will sometimes get their attention and stop them crying.
Emergency Department Care:

  • Children presenting with crying and irritability require an extensive history and physical examination by someone comfortable with the care and management of children.
  • Crying and irritability are vague symptoms; therefore, the overall appearance and stability of the child should guide the diagnostic workup.

  • Even if the child appears healthy and is thought to have a benign, nor-life-threatening condition (e.g., colic), one needs to provide detailed instructions to the family regarding what signs are concerning and when to return for medical care.
  • If the child appears ill, has fever, is inconsolable, is lethargic, or if other concerns of infection exist, a workup for sepsis must be performed.
Medication:
No single medication for the treatment of the broad spectrum of illnesses that can cause crying and irritability can be recommended. Specific therapy can be prescribed only after efforts at obtaining a diagnosis are successful. For example, a corneal abrasion would be treated by the appropriate topical ophthalmic antibiotic, while otitis media can be treated by any number of appropriate oral/parental antibiotics.
Follow up
Further Inpatient Care:

  • Need for inpatient management is dependent upon the specific cause of crying and irritability.

  • Hospitalization for observation may be necessary for children with unclear etiologies.

Further Outpatient Care:
In many cases, a specific cause of crying and irritability may not be found.
If life-threatening causes can be ruled out through history, physical examination, and appropriate screening studies, patients with resolution of symptoms and excellent follow-up care can usually be followed as outpatients. In these cases, close follow-up care should be arranged and families should be instructed to return immediately if any worsening occurs or if new concerns develop.

Medical/Legal Pitfalls:

  • Failure to arrange for appropriate follow-up care.

  • Failure to adequately observe prior to discharge (-2 h).

  • Failure to completely document a thorough history and physical examination.

  • Vague or incomplete discharge instructions to the family.

Conclusion
Crying may be normal or range from a crying for a benign lesion to a life threatening condition like meningitis.
Crying is a vague symptom so proper & full systemic examination is needed to reach a diagnosis. Contact doctor if crying last for more than 2 hours or intermittent crying lasts for more than 2 days. First consider common physiological problem and common causes, then proceed for rare differential diagnosis.
References :
  1. Brazelton TB : Crying in infancy. Pediatrics 1962;29:579-88.
  2. Henretig FM : Crying and colic in early infancy. In: Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. 1993:144-6.
  3. Forfar & Arneils. Textbook of Pediatrics 5'edition 236.
  4. Meharban Singh, Care of the Newborn, 6th edition; 137.
  5. Ronald S. Illingworth : The Normal Child, 12th edition; 303-307.
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