The crying child: What are they trying to tell you? Part 2

CME

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This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of CME², Inc. ("cme²") and Contemporary Pediatrics. cme² is accredited by the ACCME to provide continuing medical education for physicians.

cme² designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit™. One AMA PRA Category 1 Credit™ will be awarded after the successful completion of Part I and II, which is scheduled to appear in the June issue of Contemporary Pediatrics. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Target audience: Pediatricians and primary care physicians

EDUCATIONAL OBJECTIVES

• Cite life- and limb-threatening diagnoses that may present as irritability or persistent crying in a young child
• Discuss the typical clinical course for simple colic
• Explain the utility and limits of the laboratory evaluation of the irritable young child
• Describe an algorithm for the initial evaluation and treatment of the irritable young child

To earn CME credit for this activity
Participants should study Parts I and II of this article and log on to www.contemporarypediatrics.com, where they must pass a post-test and complete an online evaluation of the CME activity. After passing the post-test and completing the online evaluation, a CME certificate will be e-mailed to them. The release date for this activity is June 1, 2007. The expiration date is June 1, 2008.

Disclosures
Editors Toby Hindin, Jeannette Mallozzi, Jeff Ryan, and Karen Woldman disclose that they do not have any financial relationships with any manufacturer in this area of medicine. Manuscript reviewers disclose that they do not have any financial relationships with any manufacturer in this area of medicine.

Author Robert Bolte, MD, discloses that he does not have any financial relationships with any manufacturer in this area of medicine.

Resolution of conflict of interest
cme² has implemented a process to resolve conflicts of interest for each continuing medical education activity, to help ensure content validity, independence, fair balance, and that the content is aligned with the interest of the public. Conflicts, if any, are resolved through a peer review process.

Unapproved/off-label use discussion
Faculty may discuss information about pharmaceutical agents, devices, or diagnostic products that are outside of FDA-approved labeling. This information is intended solely for CME and is not intended to promote off-label use of these medications. If you have questions, contact the medical affairs department of the manufacturer for the most recent prescribing information. Faculty are required to disclose any off-label discussion.

Toxicity check

It is important to optimize the physical examination, particularly in a small child with intractable crying. A brief period of non-threatening observation while the child sits in the parent's lap can yield vital information (visual interaction, playfulness, willingness to smile, respiratory rate and pattern, neck flexion and extremity movement, etc.). In fact, assessment of the child's "toxicity," which often plays a pivotal role in the extent of the work-up, is routinely ascertained during this observation period.

These data become impossible to establish, however, if the child begins to struggle during the hands-on portion of the examination. Enter the distraction. A flashing penlight, a twirling stethoscope, a set of keys, or a colorful toy can (and often do) enable the examiner to obtain more reliable information. Obviously, the most annoying aspects of the examination (tympanic membranes, pharynx, rectum) should be deferred until last. As another (somewhat obvious) example, if a "toddler's fracture" of the distal tibia is suspected, examine the hips, knees, ankles, and palpate the other areas of the lower extremities prior to directly palpating the area of highest suspicion.

In the febrile child over 12 weeks of age without obvious signs of serious illness (e.g., extreme lethargy, nuchal rigidity, bulging fontanelle, poor perfusion, hypoventilation, petechiae), a repeat exam 30 minutes following the administration of a dose of acetaminophen (15 mg/kg) or ibuprofen (10 mg/kg) may be useful in assessing toxicity. However, the patient's fever response per se does not distinguish between bacterial and viral disease.

The use of topical otic anesthetic preparations during the evaluation of a crying infant (greater than 12 weeks of age) with obvious (non-draining) otitis media can also be a helpful adjunctive technique in assessing the presence of systemic "toxicity."

Attention to detail

The physical examination should be thorough and patiently performed, with certain points deserving emphasis. In the young child with a history of sudden deterioration (i.e., cyanotic/apneic "spell" or seizure-like episode), an unexplained decrease in the level of consciousness, or sudden onset of respiratory distress without apparent intrinsic lung pathology, clinicians should consider shaken baby syndrome, and ideally follow up with a fundoscopic exam to search for any retinal hemorrhages. Attention should also be focused on the fullness of the fontanelle in the infant.

A thorough inspection of the integument is also important, as well as a careful examination of the pharynx and gums. Facial or intra-oral bruising in the non-ambulatory infant is highly suspicious for non-accidental trauma. Atypical location or pattern of a contusion or burn is also suggestive of an abusive injury. The abdomen should be palpated for tenderness or a mass, and a rectal examination (with a screen for occult blood) should be performed.

Unrecognized hypoxia can be a cause of irritability in the infant. In such cases, oxygen saturation can be deceptively low without obvious cyanosis. Therefore, pulse oximetry should be performed in the crying child with an apparent increase in respiratory effort.

In cases of possible UTI, obtaining a reliable, non-contaminated urine specimen is critically important. Catheterization should be the standard technique for obtaining specimens from both male and female children still wearing diapers. Obtaining urine for culture by "bag" specimen should be abandoned because of the notoriously high contamination rate.

In regards to laboratory tests, extensive "shotgun" routine screening tests are generally of little value for the young child with intractable crying. However, urinalysis, urine culture, and fluorescein staining of the cornea should be performed in any infant whose excessive crying is still unexplained after a thorough history and physical.

With or without fever

If the child is febrile (i.e., with a rectal temperature greater than or equal to 100.4° F ) and less than 2 to 3 months of age, a complete "septic work-up" including lumbar puncture should be considered. Hospitalization with parenteral antibiotic coverage is recommended in all febrile neonates (less than 28 days of age).¹

If the child is febrile and greater than 2 to 3 months of age, your assessment of the infant's "toxicity" as well as specific historical and physical findings determine the extent of the evaluation.² Clinicians should keep in mind that early in the course of bacterial meningitis, signs of meningeal irritability are unusual in the infant less than 6 months of age (although full fontanelle may be seen), and are not uniformly present until about 18 to 24 months of age. With aseptic meningitis or encephalitis, meningismus is often absent even in the older child. Therefore, in the febrile child a lumbar puncture is indicated, assuming that the neurological exam is non-focal and there are no signs of increased intracranial pressure.

A urinalysis should also be performed in every febrile child who presents with intractable crying or extreme irritability if the etiology is unclear. Significant bacteriuria may be present without pyuria, and conversely pyuria is not uncommon in the absence of significant bacteriuria. Moreover, infants often have UTIs despite normal urinalysis. Therefore, adequate culture techniques are necessary for accurate diagnosis.

A complete blood cell count with differential and a C-reactive protein may be helpful screening tests. However, a normal white blood cell count and C-reactive protein do not completely exclude a meningitis or sepsis diagnosis. A chest roentgenogram and blood culture should also be considered, particularly if your patient exhibits respiratory symptoms, or if the child's white blood cell count is markedly elevated.

In the afebrile child who presents with intractable crying of obscure etiology, a urinalysis should be performed. In addition, among infants, an inspection of the eyes with fluorescein is indicated to exclude an "occult" corneal abrasion or foreign body. Even if the above screening tests are negative, you should be wary in labeling the crying, afebrile infant as suffering from "colic" unless the symptoms are clearly recurrent in nature and follow the usual temporal course of classical infant colic syndrome.

If after evaluation colic is thought to be the likely diagnosis, treatment options should include teaching parents on the natural history of colic (a potential "light at the end of the tunnel") and empathetic reassurance.^3-5 In addition, two literature reviews^6,7 conclude that decreasing the stimulation of the infant's environment (decreasing light/noise in the baby's bedroom, use of nap-time swaddling, etc.) is a reasonable evidence-based approach to treatment of colic.

A change in the menu?

In general, empiric formula changes are frustratingly ineffective and should not be recommended.^8,9 However, a small subset of children may respond to a trial of hydrolysate formula.¹⁰ Simethicone (0.3 mL prior to each feeding) is safe and non-toxic although it is only a high-grade placebo.¹¹ Commercial herbal/chamomile tea in small amounts is essentially non-toxic and in a 1993 study by Weizman was found to be superior to placebo.¹²

If gastrointestinal reflux/esophagitis is thought to be the cause of the infant's irritability, a brief trial of an antacid (2.5 mL given five minutes before each feeding time for two to three days) and/or a two-week trial of ranitidine (Zantac) with follow-up is a reasonable treatment option. Prescription of anti-spasmodic agents or paregoric should be avoided.

Warning signs

The emphasis in the emergent evaluation of the infant with intractable crying is to exclude serious underlying illness (see Table 1). In Poole's 1991 study of afebrile infants, those who ceased crying before or during the initial assessment were less likely to have a serious underlying illness, whereas persistent, excessive crying after the initial exam was foretelling of a serious underlying process.¹³

Fortunately, there are certain "red flags" in the history and physical which suggest significant underlying pathology (see Table 2). The presence of any of these findings should prompt more extensive evaluation and aggressive management, often including hospitalization and specialty consultation.

Keeping a watchful eye

As with most clinical situations in the office, urgent care center, or emergency department, arrangement of close follow-up is of paramount importance. This is particularly crucial when the etiology of the crying at discharge is still somewhat obscure, or if parenteral antibiotics have been administered.

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References

1. Baraff LJ, Bass JW, Fleisher GR, et al: Practice guidelines for the management of infants and children 0 to 36 months of age with fever without source. Pediatrics 1993;92:1

2. Baskin MN, O'Rourke EJ, Fleisher GR: Outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone. J Pediatr 1992;120:22

3. Taubman B: Parental counseling compared with elimination of cow's milk or soy milk protein for the treatment of infant colic syndrome: A randomized trial. Pediatrics 1988;81:756

4. Fleisher DR: Coping with colic. Contemp Pediatr 1998;15(6):144

5. Clifford TJ, Campbell MK, Speechley KN, et al: Sequelae of infant colic: evidence of transient infant distress and absence of lasting effects on maternal health. Arch Pediatr Adolesc Med 2002;156:1183

6. Lucassen PL, Assendelft WJ, Gubbels JW, et al: Effectiveness of treatments for infantile colic: systematic review. BMJ 1998;316:1563

7. Garrison MM, Christakis DA: A systematic review of treatments for infant colic. Pediatrics 2000;106:184

8. Hardoin RA, Henslee JA, Chistenson CP, et al: Colic medication and apparent life-threatening events. Clin Pediatr 1991;30:281

9. Myers JH, Moro-Sutherland D, Shook JE: Anticholinergic poisoning in colicky infants treated with hyoscyamine sulfate (Levsin). Am J Emerg Med 1997;15:532

10. Lucassen PL, Assendelft WJ, Gubbels JW, et al: Infantile colic: crying time reduction with a whey hydrolysate: A double-blind, randomized, placebo-controlled trial. Pediatrics 2000;106:1349

11. Metcalf TJ, Irons TG, Sher LD, et al: Simethicone in the treatment of infant colic: A randomized, placebo-controlled, multicenter trial. Pediatrics 1994;94:29

12. Weizman Z, Alkrinawi S, Goldfarb D, et al: Efficacy of herbal tea preparation in infantile colic. J Pediatr 1993;122:650

13. Jenny C, Hymel KP, Ritzen A, et al: Analysis of missed cases of abusive head trauma. JAMA 1999;281:621