It was disconcerting to find that while we had a combined clinical experience of over twenty years as emergency physicians, after having treated over 100,000 patients (including at least 20,000 pediatric patients), when our baby cried and we couldn’t figure out why, we instantly went into panic mode.
The complete differential diagnosis of excessive crying in an infant is enormous.
It’s midnight on a tuesday and a couple have presented to your hospital’s ED with 7 week old Jonny who will just not stop crying.
A social visit or your most dangerous presentation tonight?
Crying is a common behavior of infancy that can be a signal of a broad spectrum of conditions ranging from the normal needs of hunger and sleep to significant medical or surgical pathology.
Unfortunately, there is no consensus as to what constitutes excessive crying. Infant colic has been described by the “rule of 3”: crying that lasts > 3 hours per day, for > 3 days per week in an otherwise healthy infant between 3 weeks and 3 months of life. However, it is important to note that infant colic is a diagnosis of exclusion, and the acute presentation of excessive crying may indicate significant pathology.
The degree of parental concern has been shown to correlate with disease severity in infants. Parents can differentiate the cries of their infants and can intuit pathology as well. Parental concern should be one of multiple features to factor into the evaluation of a crying infant and should not be dismissed by providers.
Determining the medical history and performing a physical examination remain the cornerstones for the evaluation of a crying infant and should drive investigation selection.
Whilst most scenarios are benign (95%) needing no tests, parent fears must be heard. Balancing reassurance against not missing serious illness or early psychosocial stress.
Without question, one of the most challenging tasks in life is to raise a child. The degree of difficulty of this challenge is heightened when that child becomes “inconsolable.” Since a young infant or child has a limited repertoire to convey illness, constant crying needs to be taken seriously by us in the Emergency Department. So, before you jump to the conclusion that this is merely “Colic” in the 2 month old, let us quickly highlight some entities that should be at the top of your DDx when evaluating the inconsolable child.
Every infant that presents to the emergency department with the chief complaint of “crying” or “irritability” warrants a careful history and thorough physical exam. The differential diagnosis for crying is broad and involves every organ system.