crying baby practical approach
TRANSCRIPT
CRYING CHILD –PRACTICAL APPROACH
DR M R BHALERAODNB (PED)CONSULTANT PEDIATRICIAN,OLD SANGVI,PUNE 411027
Babies cry because they cannot Talk !
Crying is Baby Communication !
INTRODUCTION
Most common complaint , for which the child is brought to Pediatrician/ Primary Physician
Lot many reasons why child cry ! Prevalence of excessive crying 1.5 – 40 %
UK study annual cost of 108 million dollars spent by NHS on care of infants with crying & difficulty in sleeping in 1st 12 wks alone
INTRODUCTION
We have to differentiate when the cry is an abnormal & find out the reason behind it
Each case should be looked as a clinical challenge rather than as annoyance
Fear of missing a diagnosis may result in unnecessary & invasive tests
Introduction Crying is an important cause of maternal anxiety & stress, strongly
associated with maternal depression.
Can affect breast feeding
Stress in relationships – mother-infant , mother- family members , mother – father relationship
Can be associated rarely with physical violence
How much crying is normal ? Brazelton ( 1962)-studied babies from birth -
12wks
Infants in their 2nd wk of life cried & fussed for median 1.75 hrs, which increased to a peak median of 2.75 hrs at 6 wks, after which there was decline in the amount of crying
There appears circadian pattern , concentrated most in late afternoon and evening.
Colic in infants Illingworth (1954 )- described 50 infants <
3months with’ rhythmic attacks of screaming’ ,without any inciting cause & labeled them as “ Three months colic”
Wessel et al used the term “ paroxysmal fussing “ .
Amount of crying that is considered excessive is accepted from Wessel’s studies (>3 hrs)
Acute crying –role of a physician (1) to avoid missing a serious or life-
threatening aetiology & (2) to determine the common/treatable
diagnoses . In their study of 200 crying infants who
presented to the ED, Fahimi et al found that the 3 most common diagnoses were colic (29.5%), acute otitis media (15.5%), and constipation (5.5%)
Non pathological causes
Hunger, thirst, tiredness ,discomfort
Separation from mother
Temperature disturbances in the environment
Need to clean up
Pathological causes of crying Most of the diseases of neonates,
infants and children have irritability as a major manifestation.
For pediatrician it is important to decide the cause of irritability/crying, though difficult at times
Crying …. Complaint of crying is so nonspecific,
differential diagnosis is so extensive,
THOROUGH HISTORY , CLINICAL EXAMINATION
TOP UP WITH
YOUR CLINICAL EXPERIENCE !!!
Assessment of the baby parental concern was “red flag” in identifying
serious illness, with a positive likelihood ratio (LR) of 14.4 (95% confidence interval [CI] 9.3-22.1 (Van den Bruel et al )
Clinician’s concern : “gut feeling” that something was wrong, despite the assessment, substantially increased the likelihood of serious illness with a LR of 25.5 (95% CI, 7.9-82)
history as diagnostic in 20% to 86% of cases, alone
or in conjunction with physical examination findings
Studies ( Poole et al ) Poole et al- emergency department visits
with ages ranging 4 days- 24 months-
61 % had diagnosis that was serious illness, of those history provided clues in 20 %
physical examination provided Dx in 41%
& clues leading to Dx in 13%, remaining 24% continued to cry after initial assessment
Systematic approach to crying patient Examine patient from head to toe literally
!!
General examination: temperature, pulse, respiration ( vitals ), hydration of the baby
Examination of head: anterior fontanel (boggy/ depressed )
prominent veins over scalp sutural separation
Examination
Ears : otoscopy ( AOM/ MEE) discharge from ears foreign body
Nose : sinusitis bloody discharge ( foreign body )
Throat : vesicles (herpangina ) pooling of secretions
( parapharyngeal abscess)
Acute otitis media
Herpangina
Oral candidiasis
Examination
Eyes : foreign body ,injury, intraocular pressure ( corneal enlargement in glaucoma)
Neck : e/o swelling , abscess, LN suppuration
Mouth : apthous ulcers, oral candidiasis, stomatitis
EXAMINE EYES FOR – FB, INJURY, CLOUDY CORNEA ETC
Examination
Respiratory system : tachypnea , crepts/ bronchial breathing , e/o foreign body
Per Abdomen : mass / lump in abdomen (intusseption ) , P/R exam if required Don’t forget to undress the child -- impacted inguinal hernia, torsion of testis may be missed
Torsion right testis Impacted lt inguinal hernia
INTUSUSEPTION
Musculoskeletal system exam Examine all bones and joints
carefully to exclude fractures
joints for e/o septic arthritis , transient synovitis
look for pseudo -paralysis as in Scurvy
SCURVY XRAY
Examination
CNS : most important to r/o Intracranial infection
Examine for toxicity, see neuro behavior of the child, feeding history ,convulsions, focal neurological signs.
Genitourinary system : dysuria, perivulval/perianal redness , labial synaechiae
Labial synaechiae ( before separation)
Labial synaechiae ( after separation)
Summary of causes
Head & eyes : 1. trauma
2. corneal abrasion
3. ocular/nasal/ear foreign body
4. glaucoma
5. panniculitis
Summary of causes Respiratory system :
UR system – blocked nose acute otitis media foreign bodies
LR system – bronchiolitis pneumonia foreign bodies pneumothorax
Summary of causes
Cardiovascular : 1. congestive heart failure
2. supraventricular tachycardia
3. endocarditis , myocarditis
4. myocardial infarction
Summary of causes Gastrointestinal & genitourinary system : colic ( evening colic, colic associated with
AGE, dysentery etc)
Intusseption ,bowel obstruction, volvulus colitis , appendicitis
Impacted feces / constipation GERD , esophagitis anal fissure, hemorrhoids
Summary of causes
Gastrointestinal & genitourinary system(cont.):
milk protein allergy incarcerated inguinal hernia testicular torsion Urinary retention, urinary tract
infection balanitis / balanopsthitis
Summary of causes
Musculoskeletal system :
fracture osteomyelitis arthritis vaso-occlusive crisis ( sickle cell
anemia ) dactylitis
Summary of causes Central nervous system :
meningitis / encephalitis
intoxication , neonatal drug withdrawal
causes of raised ICP ( hydrocephalus, mass , ICH, cerebral edema
pseudotumour cerebrii
Summary of causes
Dermatologic : burns
Cellulitis
insect bites / urticaria
atopic dermatitis / mastocytosis
Summary of causes Miscellaneous causes :
drug overdoses ( nalidixic acid, Vitamin A etc)
post vaccination ( DPwT) recovery from neurological diseases
Scurvy
treatment 1) Infants with clear diagnosis/
identifiable cause
(2) infants who continue to cry without a clear, identifiable cause
---outpatient follow up visit within 24 hours----avoidance of medicating unknown / unclear
diagnosis--- reassurance and supportive measures to
the parents
Considering special situations Consider common diagnosis first
Rule out serious underlying disorders
Colic has historically been defined as paroxysms of excessive crying lasting > 3 hours per day, occurring > 3 days in any week for 3 weeks, in an otherwise healthy baby aged 2 weeks to 4 months. It is estimated to affect 10% to 30% of infants worldwide.
Causes of colic
Proposed causes include: cow’s milk protein allergy or
intolerance, gastrointestinal reflux disease,
feeding difficulties, sleep difficulties,
and neurodevelopmental immaturity
Baby parent interaction
Time & cost effective strategies Don’t initiate extensive & expensive work
up on every crying patient
May not be possible to identify the correct etiology during Emergency visit , can arrange follow up visit
Don’t forget urine analysis
For Crying Infants Criteria For Admission
Toxic-appearing Hemodynamically unstable , critical illnessClinically stable with a condition requiring IV therapy (fluids, antibiotics)
No access to immediate follow-up care Ongoing crying without a clear-cut etiology after examination, observation, and appropriate testing
Social concerns (poor support at home, unsafe environment for the infant, risk factors for abuse or neglect)
Admission criteria for crying babies
1.Well-appearing/consoled Clinically stable with a condition treatable in outpatient therapy (oral antibiotics, analgesics)
2.Access to immediate follow-up care Resolution of crying in the ED or ongoing crying that is baseline or not concerning to provider or caregiver
3.No social concerns Parents are comfortable with discharge plan and understand next steps regarding treatment and follow-up
.
Criteria for discharge from ED
Excuses / myths during assessment
“The baby did not have a fever, so I did not consider that he could have a serious infection
“Of course the baby had an elevated heart rate; he was crying
The parents seem really nice, so there is no need to consider nonaccidental trauma.”
Excuses during assesment “All babies cry. This is a normal finding and
is nothing to worry about.” ( thik ho jayega) “The more tests I perform, the closer I will be to
making a diagnosis
“This baby just has colic”
“Parents are always anxious about their babies, but it doesn’t mean anything is truly wrong with the infant.”
Carry home messages History and clinical examination …the most
important tools
No universally recommended lab tests/ imaging studies….. Individualize the decisions
Colic & unexplained crying are the most common, than underlying serious pathologies
Don’t miss underlying serious disorder
Summary – ’ IT CRIES’ I – Infections ( herpes stomatitis, UTI,
meningitis, osteomyelitis & so forth )T – Trauma ( accidental/non accidental ),
testicular torsionC - Cardiac ( congestive cardiac failure, SVT
)R – Reflux, reaction to medications/formulas I – Immunizations, insect bitesE – Eye ( corneal abrasions, FB, glaucoma)S – Surgical ( volvulus,intusseption, hernia)
GOOD NIGHT & HAVE SWEET DREAMS !
Infantile colic
Infantile colic
Behavioral state, characterized by unexplained paroxysms of inconsolable crying , lasting for more than 3 hrs a day & occurring more than 3 days in a week, for a period of 3 weeks .
Occurs in 10-25% of infants
Onset is usually 2-3 wks of age , peaking at 6-8 wks and remitting at 3-4 months of age
Infantile colic ( cont.)
Episodes usually occurs during evening hours
Infant may grimace, pass flatus , clench his/her fists and draw up his/her legs
Cry is prolonged ,loud, high pitched – described as piercing
Infantile colic-- causes
Colic is a diagnosis of exclusion
Exact cause of colic not known , many possibilities thought of—
Gastrointestinal causes Neuropsychological causes Food allergies parental misadventures
Infantile colic --causes
a) carbohydrate malabsorption
b) lactose in the diet, CMPA
c) increased gas in the infants with colic ??
d) behavioral factors such as feeding abnormalities ,infant positioning while feeding
e) Psychological factors suggested possible etiologies like underdeveloped parenting skills, parental anxiety, stress
For diagnosis of colic, routinely lab investigations are not required, unless you suspect something else
Factors aggravating colic Overfeeding in an attempt to lessen
crying
Feeding certain foods ,especially those with sugar content , may increase amount of gas in the intestines ( e.g. undiluted fruit juices )
Presence of excessive anger, fear, excitement in household
Multiple factors as yet unknown
Treatment of infantile colic Reassuring the parents that colic is self-
limited. Encourage parental rest breaks, developing strategies for crying episodes
Folk remedies ( herbal teas- licorice, dill oil,fennel oil ) ?? Efficacy
Behavioral modifications-positioning of infant during feeding, early response to crying –shown not to be effective
Treatment of infantile colic--cont Medications targeting GI system
( simethicone Vs placebo- demonstrated equal improvement)
Dicyclomine has shown effect in some RCTs, but issues of safety ( apnea ,other serious adv effects) . Not recommended < 6 mths
? Changing formulas , ? Lactose free formulas ,addition of lactase in formula–No benefit
Low allergen diet in mother ( diet free of egg, milk, nuts, wheat, artificial colors & preservatives ).
Herbal remedies ( tea containing chamomile, vervain, licorice, fennel etc) showed some reduction in crying.
Summary And
Conclusions
Summary – ’ IT CRIES’ I – Infections ( herpes stomatitis, UTI,
meningitis, osteomyelitis & so forth )T – Trauma ( accidental/non accidental ),
testicular torsionC - Cardiac ( congestive cardiac failure, SVT
)R – Reflux, reaction to medications/formulas I – Immunizations, insect bitesE – Eye ( corneal abrasions, FB, glaucoma)S – Surgical ( volvulus,intusseption, hernia)
Conclusions
Common clinical dilemma Every case has to be individualised History & clinical examination are main
tools Ordering unnecessary test add stress to
family & cost burden ! Sick child, poor growth ,inconsolable
child deserves investgations Don’t forget possibility of abuse Support, reassuarance needed in many
IF A CHILD DOESN’T CRY ……………. …………………. ………………… …………………. ……………………..
…………………………
PEDIATRICIAN MIGHT!!!
THANKING ALL OF YOU FOR MAKING ME SMILE!!!