TABLE 20.1 CONDITIONS ASSOCIATED WITH ABRUPT ONSET OF INCONSOLABLE CRYING IN YOUNG INFANTS I Discomfort caused by identifiable illness A Head and neck Meningitis a Skull fracture/subdural hematoma a Glaucoma Foreign body (especially eyelash) in eye b Corneal abrasion b Otitis media b Caffey disease (infantile cortical hyperostosis) Child abuse a B Gastrointestinal Aerophagia (improper feeding/burping technique) Gastroenteritis b Gastrointestinal surgical emergency (e.g., volvulus) a Anal fissure b Constipation b Cow’s milk protein intolerance Gastroesophageal reflux/esophagitis C Cardiovascular Congestive heart failure a Supraventricular tachycardia a Coarctation of the aorta a Anomalous origin of left coronary artery from pulmonary artery a D Genitourinary Torsion of the testis Incarcerated hernia a Urinary tract infection E Integumentary Burn Strangulated finger, toe, penis (hair tourniquet) F Musculoskeletal Child abuse a Extremity fracture Musculoskeletal infection (septic joint or osteomyelitis) a G Toxic/metabolic Drugs: antihistamines, atropinics, adrenergics, cocaine (including passive inhalation), aspirin a Metabolic acidosis, hypernatremia, hypocalcemia, hypoglycemia a Pertussis vaccine reactions Prenatal/perinatal drug exposure/withdrawal II Colic—recurrent paroxysmal attacks of crying b a Life-threatening b Common causes causes Many infants will have a completely normal emergency department evaluation, and the history (or subsequent follow-up) will be suggestive of colic Over the time in which the crying attacks recur, the infant must demonstrate adequate weight gain (average 20 to 30 g/day in the first months of life) and absence of physical disorders on several examinations before underlying illnesses can be excluded and colic can be diagnosed confidently ( Fig 20.1 ) When it becomes clear that an infant is experiencing colic, the practitioner faces the challenge of advising the family No dramatic cure is currently available, however the symptoms almost invariably resolve by months of age Furthermore, many studies on the etiology and treatment of colic have methodologic weaknesses, making it difficult for clinicians to interpret results There is no safe and effective pharmacologic or dietary treatment for colic The efficacy of simethicone is not supported by good-quality trials, but there have been no reported side effects and it is widely used Methylscopolamine is neither effective nor safe Dicyclomine, once believed to be effective, is no longer recommended in infants younger than months because it can cause apnea, seizures, and coma Studies of hypoallergenic formula and maternal hypoallergenic diets while breastfeeding have yielded mixed results, and available data does not support diet modification for colic in infants without other symptoms of cow’s milk protein allergy Studies of herbal extracts are low quality, though some have shown a decrease in crying times However there are multiple drawbacks to these, including compromised nutrition due to the large volume required for symptomatic relief, and lack of standardized dosing and strength In addition, there is a potential for parental misidentification of recommended ingredients, causing GI toxicity or neurotoxicity Chiropractic manipulation has been shown to decrease parent-reported crying time in some studies, but all are small and methodologically prone to bias, and safety concerns have been raised regarding chiropractic manipulation in small infants The most promise for symptomatic improvement has been demonstrated with probiotic supplementation Lactobacillus reuteri decreases crying times in breastfed infants with colic who received L reuteri supplementation Data is less conclusive that L reuteri supplementation reduces crying times in formula-fed infants Similarly, studies of multiple other probiotic strains have not consistently demonstrated reductions in colicky crying L reuteri is safe in immunocompetent infants Based on available evidence, the safest and most effective course of treatment seems to be empathy, and counseling to respond quickly to the crying infant The physician can reassure the parents that their baby is thriving and will outgrow the colic and develop normally, and that the crying is not due to their parenting It is reasonable to recommend a trial of supplementation with L reuteri in immunocompetent infants, with counseling that it is likely more effective in breastfed infants However, other medications, dietary interventions, or complementary therapies are not currently recommended Colic is not dangerous and does not last forever, but it will be a nuisance for several weeks Exhaustion of the parents may be dangerous for the infant, both psychologically and physically Excessive crying is a known risk factor for abusive head trauma The physician should assess the parents’ emotional state, investigate the status of available support systems, and recommend a respite for the primary caregivers if possible For amelioration of crying at the time of the ED visit, no drug therapy or feeding change is recommended Rather, most colicky babies derive some temporary relief from rhythmic motion, such as rocking, being carried, or riding in a car; from continual monotonous sounds, such as those from a washing machine or electric fan; and from nonnutritive sucking Because the differential diagnosis of infant crying is broad, referral to a pediatrician for follow-up is extremely important ... Gastrointestinal Aerophagia (improper feeding/burping technique) Gastroenteritis b Gastrointestinal surgical emergency (e.g., volvulus) a Anal fissure b Constipation b Cow’s milk protein intolerance Gastroesophageal... of crying b a Life-threatening b Common causes causes Many infants will have a completely normal emergency department evaluation, and the history (or subsequent follow-up) will be suggestive of... nonnutritive sucking Because the differential diagnosis of infant crying is broad, referral to a pediatrician for follow-up is extremely important