From the March 2014 issue of Pediatric Emergency Medicine Practice, “A Systematic Approach to the Evaluation of Acute Unexplained Crying in Infants in the Emergency Department.” Reprinted with permission. To access your EMRA member benefit of free online access to all EM Practice, Pediatric EM Practice, and EM Practice Guidelines Update issues, go to www.ebmedicine.net/emra, call 1-800-249-5770, or send e-mail to firstname.lastname@example.org.
- “The baby did not have a fever, so I did not consider that he could have a serious infection.”
Sepsis and other significant infections can present as crying, alone or in conjunction with other findings. An infant may not manifest a fever as a sign of infection or, conversely, he may be hypothermic as a manifestation of infection. For a crying infant, all serious etiologies, including infection, should be considered and investigated when appropriate, with or without the presence of fever.
- “Of course the baby had an elevated heart rate; he was crying.”
Crying can often lead to tachycardia in infants. However, tachycardia can be a manifestation of infection, dehydration, evolving fever, pain, or distress. Vital signs should be taken repeatedly on a crying infant, in both the crying and noncrying state, to avoid inappropriately attributing abnormal findings to crying rather than other potentially serious underlying causes.
- “I had a bad feeling about this baby, but how I feel shouldn't impact my investigations.”
As with parental concern, clinician concern and “gut instinct” regarding pediatric pathology has been supported as an accurate tool in determining serious illness. Emergency clinicians should acknowledge their concern and factor their intuition into an evaluation of a crying infant.
- “The parents seem really nice, so there is no need to consider nonaccidental trauma.”
Unfortunately, it is almost impossible to predict which caregivers may cause nonaccidental trauma. It must be considered in any infant with persistent or unexplained crying regardless of a family's stature or protestations.
- “All babies cry. This is a normal finding and is nothing to worry about.”
While some amount of crying is normal in all infants, any crying that exceeds the duration or quality of the infant's typical crying, is concerning to parents or providers, or is accompanied by a change in behavior should be considered significant and potentially pathologic until proven otherwise. The spectrum of normal crying for an infant is variable by age and by individual infant, so caregiver descriptions of deviations should be taken seriously.
- “If I am not going to perform any diagnostic tests (such as blood, urine, imaging), I should just send this baby home. There is no reason for him to sit around in the ED.”
Observation and serial examinations are paramount to the evaluation of a crying infant for whom a diagnosis is not immediately clear. This may allow for the acquisition of additional information to guide further ED testing, allow for clinicians and caregivers to follow a trajectory of illness in the ED, and provide relief for stressed caregivers and time for education.
- “The more tests I perform, the closer I will be to making a diagnosis.”
There is no one test or series of tests universally recommended for the evaluation of a crying infant. History and physical examination remain the cornerstone of diagnosis in crying infants. “Kitchen sink” testing is expensive, invasive, and inappropriate for most infants who present to the ED with acute unexplained crying.
- “This baby just has colic.
Colic and unexplained crying are common diagnoses, but should only be applied to infants for whom other etiologies for acute crying have been considered first.
- “This baby seems fine; there is no need for this family to follow up with their primary care provider.”
Close follow-up is critical for crying infants evaluated in the ED. First, it ensures a second visit to document improvement or worsening for diagnosed conditions in which treatment may have been instituted. Second, it allows an additional diagnostic examination for infants in whom the ED visit was unrevealing and in whom an illness may now be more apparent. Lastly, it ensures a session with the primary care provider, someone who can provide reassurance and support to the family on a more long-term basis.
- “Parents are always anxious about their babies, but it doesn't mean anything is truly wrong with the infant.”
The degree of parental concern has been shown to correlate with disease severity in infants. Parents can differentiate the cries of their infants and can intuit pathology as well. Parental concern should be one of multiple features to factor into the evaluation of a crying infant and should not be dismissed by providers.