Ralston SL, Lieberthal AS, Meissner C, et al Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis Pediatrics 2014;134(5):e1474–e1502 Sink JR, Kitsko DJ, Georg MW, et al Predictors of foreign body aspiration in children Otolaryngol Head Neck Surg 2016;155(3):501–507 Vernacchio L, Kelly JP, Kaufman DW, et al Cough and cold medication use by US children, 1999–2006: results from the Slone survey Pediatrics 2008;122(2):e323–e329 Zorc JR, Scarfone R, Reardon A, et al ED Pathway for Asthma, Emergent Care The Children’s Hospital of Philadelphia Posted: May 2018 Last revised: October 2018 Available at https://www.chop.edu/clinical-pathway/asthmaemergent-care-clinical-pathway CHAPTER 20 ■ CRYING EMILY L WILLNER, SHILPA J PATEL INTRODUCTION For the purposes of this chapter, we limit our discussion to crying in early infancy, that is, the first months of life Infant crying is a nonspecific response to discomfort, with causes ranging from normal hunger and desire for company to life-threatening illness Many common minor irritations and illnesses can be elucidated by careful history and physical examination One in five normal, thriving babies will develop a pattern of unprovoked daily paroxysms of irritability and crying known as colic Colic usually begins in the second to third week of life, with complete resolution by months of age Crying, associated with colic, may last for several hours each day and is more common in the late afternoon or evening A typical episode is described as sudden fussiness that develops into a piercing scream, as if the baby were in pain The infant may draw up the legs, the abdomen may appear distended, bowel sounds are increased, and flatus may be passed, leading parents to be concerned that their baby has abdominal distress Only when crying episodes are repeated and stereotypical, and other causes of crying are excluded, can a diagnosis of colic be made with certainty When colic is suspected, the emergency physician must have an orderly approach in order to rule out severe, life-threatening illnesses, detect common medical etiologies, and provide preliminary guidance to the family PATHOPHYSIOLOGY Any unpleasant sensation can cause an infant to cry Pain or an altered threshold for discomfort (irritability) may be caused by many physical illnesses Those most likely to present abruptly in a young infant are listed in Table 20.1 Numerous unproven theories abound about the etiology of colic, including cow’s milk or other allergy or food sensitivity, immaturity of the gastrointestinal tract or central nervous system, parental anxiety, maternal smoking during pregnancy, poor feeding technique, and individual temperament characteristics Gastroesophageal reflux has been suggested as a possible etiology of infant colic; however, anti-reflux medications are not superior to placebo in reducing colicky crying Moreover, there is poor correlation between crying and reflux episodes documented by pH probe The search for a specific cause of colic continues No single theory (or therapy) has gained uniform acceptance Colic may be a syndrome that represents the manifestations of some or all these factors in varying degrees in a population of babies whose tendency to cry varies along a normal distribution Multiple studies have documented crying in early infancy They show that crying tends to cluster in the evening, and daily crying times increase from birth to a peak of approximately hours per day at to weeks, followed by a rapid decline Although there are variations in the literature, most agree that a reasonable definition for colic embraces Wessel criteria: an infant younger than months of age with more than hours of crying per day occurring more than times per week for more than weeks EVALUATION AND DECISION A careful history, physical examination, and rarely, additional studies, should enable the physician to diagnose identifiable illnesses or injuries causing severe paroxysms of crying ( Table 20.1 ) The history should elicit the onset of crying and any associated events— particularly trauma, fever, use of medications, or recent immunization (irritability lasting up to 24 hours has been described after pertussis vaccination, however this is less common with DTaP than historically reported after DTP) Because feeding is vigorous exercise for the young infant, irritability with feeds may indicate ischemic heart disease Alternatively, yeast infections of the mouth, or severe reflux, may cause infants to cry with feeding Parents may recall a pattern of crying after maternal ingestion of specific foods in infants who are breastfeeding Irritability on being picked up (“paradoxic irritability”) may indicate a fractured bone or meningeal inflammation Crying with manipulation of an arm may indicate a clavicle fracture sustained during birth Physical examination must be thorough, with the infant completely undressed Vital signs may reveal either low or high temperature—suggesting infection (see Chapter 31 Fever ), or hyperpnea—suggesting metabolic acidosis (see Chapter 95 Metabolic Emergencies ) or increased intracranial pressure The head should be explored for evidence of trauma and the fontanel should be palpated Eyes must be examined with fluorescein to look for corneal abrasion, even in infants with no symptoms referable to the eyes In addition, eversion of the upper eyelids can exclude a foreign body Fundoscopy should be attempted because retinal hemorrhages are common signs of abuse, especially in abusive head trauma Careful otoscopy is required to visualize the tympanic membranes The heart should be evaluated for signs of congestive failure or arrhythmia ( Table 20.1, I.C ) Abdominal examination must be performed to detect signs of peritonitis (see Chapter 116 Abdominal Emergencies ) or incarcerated umbilical hernia The diaper must be removed and the area examined for incarcerated inguinal hernia, testicular torsion, hair tourniquet of the genitalia, or anal fissure Careful palpation of all long bones may reveal subtle signs of fracture, even in the absence of external signs of trauma Each finger and toe should be inspected to look for strangulation by hair or thread Consideration of laboratory or radiographic evaluation is made in light of the clinical findings Crying may be the primary symptom of an occult urinary tract infection, therefore urinalysis and culture of a sterile specimen of urine should be considered A low threshold for urine toxicology screening is warranted in the baby who remains inconsolable, given that intoxication (see Chapter 102 Toxicologic Emergencies ) with, or withdrawal from, illicit drugs may cause irritability Examination of the stool for blood and eosinophils may help to diagnose milk protein allergy if there is clinical concern Infants with unexplained, incessant crying, even after an observation period and attempts to calm the infant in the ED, may require further evaluation and hospitalization ... crying are excluded, can a diagnosis of colic be made with certainty When colic is suspected, the emergency physician must have an orderly approach in order to rule out severe, life-threatening