Pediatric emergency medicine trisk 124

TABLE 20.1
CONDITIONS ASSOCIATED WITH ABRUPT ONSET OF
INCONSOLABLE CRYING IN YOUNG INFANTS


I. Discomfort caused by identifiable illness
A. Head and neck
1. Meningitis a
2. Skull fracture/subdural hematoma a
3. Glaucoma
4. Foreign body (especially eyelash) in eye b
5. Corneal abrasion b
6. Otitis media b
7. Caffey disease (infantile cortical hyperostosis)
8. Child abuse a
B. Gastrointestinal
1. Aerophagia (improper feeding/burping technique)
2. Gastroenteritis b
3. Gastrointestinal surgical emergency (e.g., volvulus) a
4. Anal fissure b
5. Constipation b
6. Cow’s milk protein intolerance
7. Gastroesophageal reflux/esophagitis
C. Cardiovascular
1. Congestive heart failure a
2. Supraventricular tachycardia a
3. Coarctation of the aorta a
4. Anomalous origin of left coronary artery from pulmonary artery a
D. Genitourinary
1. Torsion of the testis
2. Incarcerated hernia a

3. Urinary tract infection
E. Integumentary
1. Burn
2. Strangulated finger, toe, penis (hair tourniquet)
F. Musculoskeletal
1. Child abuse a
2. Extremity fracture
3. Musculoskeletal infection (septic joint or osteomyelitis) a
G. Toxic/metabolic
1. Drugs: antihistamines, atropinics, adrenergics, cocaine (including
passive inhalation), aspirin a
2. Metabolic acidosis, hypernatremia, hypocalcemia, hypoglycemia a
3. Pertussis vaccine reactions
4. 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 3 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 6 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.