CRYING

EMILY L. WILLNER, MD AND SHILPA PATEL, MD, MPH

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. Often, however, a normal, thriving baby 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 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 15.1. Numerous unproven theories abound about the etiology of colic, including cow’s milk allergy, 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, studies have shown antireflux 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 15.1).

The history should elicit the onset of crying and any associated events—particularly trauma, fever, use of medications, or recent immunization (extreme irritability lasting up to 24 hours has been described after pertussis vaccination). 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 breast-feeding. 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, or hyperpnea (see Chapter 87 Fever in Infants

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