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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 3 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 3
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 3 hours per day at 6 to 8 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 3 months of age with more than 3 hours of crying per day occurring
more than 3 times per week for more than 3 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.