Perspective

More than 20% of emergency department (ED) visits are by pediatric patients, and a large proportion involve children 4 years or younger.^1,² Common reasons for ED visits in this age group include traumatic injuries, fever, respiratory complaints, and gastrointestinal problems.³^–⁵ Although many of the disease processes are self-limited, it is imperative that the emergency practitioner (EP) identify infants and children at risk for progression to serious illness.

Knowledge of developmental milestones and age-specific manifestations of illness, in addition to taking a thorough history and physical examination, will greatly enhance the clinician’s ability to diagnose and initiate appropriate therapeutic interventions. From early infancy to the toddler stage, remarkable developmental changes occur. Understanding the changes in language, motor, cognitive, and social skills is important to properly assess infants and toddlers (Fig. 16.1). Many of the common illnesses experienced are age related (Table 16.1), and early recognition of the signs and symptoms of the specific diseases that threaten infants and toddlers is an effective strategy. Taking an “AMPLIFIEDD” history (Box 16.1) and performing a “head-to-toe” physical examination allow the clinician to gather the clinical clues needed to generate a comprehensive differential diagnosis. Practitioners in the ED are encouraged to develop an expanded differential diagnosis by using their knowledge of anatomy to aid memory (Table 16.2).

Fig. 16.1 Easy-to-remember developmental milestones for the emergency department practitioner.

Table 16.1 Age-Related Differential Diagnosis for Various Chief Complaints (Overlap Can Occur)

	INFANTS	TODDLERS
Respiratory Complaints
Cough	Upper respiratory infection Bronchiolitis Croup Pertussis Pneumonia (viral or bacterial) Tracheoesophageal fistula Swallowing incoordination Bronchogenic cyst Vascular ring Foreign body aspiration	Upper respiratory infection Asthma Croup Postnasal drip Pneumonia (viral or bacterial) Foreign body aspiration Allergy, anaphylaxis
Wheezing	Bronchiolitis Reactive airways disease Foreign body aspiration Bronchopulmonary dysplasia Tracheobronchomalacia Gastroesophageal reflux Congenital lobar emphysema Vascular ring Pulmonary edema (secondary to congenital heart disorders)	Asthma Foreign body aspiration Allergic reactions, anaphylaxis Mediastinal mass (tumor or lymphadenopathy)
Gastrointestinal Complaints
Vomiting	Sepsis Meningitis, encephalitis Central nervous system mass Head injury Hydrocephalus Posttussive emesis Pneumonia Gastroesophageal reflux disease Gastroenteritis Pyloric stenosis Intussusception Malrotation with volvulus Incarcerated hernia Hirschsprung disease Peritonitis Congenital adrenal hyperplasia Urinary tract infection Inborn errors of metabolism	Sepsis Meningitis, encephalitis Central nervous system mass Head injury Hydrocephalus Appendicitis Intussusception Gastroenteritis Incarcerated hernia Peritonitis Diabetic ketoacidosis Neoplasm (Wilms tumor, neuroblastoma) Urinary tract infection
Abdominal pain	Trauma (intentional and nonintentional) Malrotation with volvulus Intussusception Gastroenteritis Constipation Incarcerated hernia Malabsorptive diseases (celiac disease, lactase deficiency) Hirschsprung disease Hemolytic-uremic syndrome	Trauma (intentional and nonintentional) Appendicitis Intussusception Gastroenteritis Constipation Diabetic ketoacidosis Incarcerated hernia Hemolytic-uremic syndrome Neoplasm (Wilms tumor, neuroblastoma)
Neurologic Complaints
Seizures	Febrile seizure Toxic ingestion Hypoglycemia Hyponatremia Pyridoxine-dependent seizures Meningitis Encephalitis Inborn errors of metabolism Traumatic head injury Myoclonic encephalopathy Early infantile epileptic encephalopathy Benign infantile seizures	Febrile seizure Toxic ingestion Hypoglycemia Meningitis Encephalitis Traumatic head injury Lennox-Gastaut syndrome Childhood absence epilepsy Partial benign epilepsy

Box 16.1 The “AMPLIFIEDD” History

Allergies: to medications, environmental allergens

Medications: prescription, over the counter, natural remedies

Past medical or surgical history:

– Birth history

– Congenital anomaly

– Chronic disease (e.g., inborn error of metabolism, endocrinopathy)

– Previous infections

– Surgeries

Last “feed, pee, poop”: Feeding, stool, and urine pattern; use of formula (dilution?)

Immediate events (history of present illness and review of systems): OLD CAARS

– Onset: Rapid or gradual

– Location: Evidence of localized pain?

– Duration and progression of symptoms

– Characterization of symptoms

– Alleviating factors of symptoms

– Aggravating factors of symptoms

– Recurrence of symptoms: ever had similar manifestation?

– Severity and system review

Family and social history

– Inherited disorders

– Day care: Who cares for child?

Immunizations up to date?

Emergency medical service history: Elicit history of potential trauma, ingestion, abuse, or toxin exposure

Doctor: Name of primary care physician or specialist for additional information and help

Documents: Obtain previous medical records

Table 16.2 The “Head-to-Toe” Memory Tool

“HEAD-TO-TOE” PHYSICAL EXAMINATION	POTENTIAL CLINICAL FINDINGS	GENERATE “HEAD-TO-TOE” DIFFERENTIAL DIAGNOSIS (EXAMPLES)
Head	Bulging fontanelle Step-off, laceration, ecchymosis, hematoma Ventriculoperitoneal shunt	Central nervous system infection Meningitis Encephalitis Intracranial abscess Closed head injury Ventriculoperitoneal shunt malfunction Central nervous system tumor Cerebrovascular accident: ischemic or hemorrhagic Seizure
Eyes	Icterus, conjunctival injection, cranial nerve deficit, retinal hemorrhage	Bile obstruction, hemolysis, foreign body or abrasion, shaken baby syndrome
Nose	Congestion	Upper airway distress (<6 mo)
Mouth	Poor dentition	Toxin ingestion or exposure Oral infection
Neck	Mass	Thyroid or parathyroid disease Adenitis
Chest Pulmonary Cardiac	Chest wall tenderness Stridor, rales, rhonchi, wheezing, murmur, dysrhythmia	Trauma (e.g., child abuse) Croup, tracheitis, pneumonia, bronchiolitis, asthma Congenital heart disease, myocarditis, supraventricular tachycardia
Abdomen Gastrointestinal tract Liver Pancreas Kidney and urinary tract Adrenal glands	Distention, tenderness, peritoneal signs, palpable mass	Gastroesophageal reflux, malrotation, pyloric stenosis, intussusception, hernia, appendicitis, Hirschsprung disease, constipation Liver: inborn error Pancreas: hypoglycemia, diabetic ketoacidosis Urinary tract: electrolyte disorder, infection, torsion Adrenal: congenital adrenal hyperplasia
Extremities	Deformity, tenderness, edema, induration, erythema	Fractures Nonaccidental trauma Accidental trauma Osteomyelitis, septic arthritis, toxic synovitis Rhabdomyolysis
Skin	Rash, petechiae	Abscess, cellulitis, omphalitis, mastitis, burn, anal fissure, sepsis
Neurologic	Weakness, decreased reflexes	Guillain-Barré syndrome, botulism

Documentation

Infant or Toddler in the Emergency Department

Document consideration of life-threatening diagnoses.

Create a word picture of the child: minor or serious illness; for example:

• “Child is playful, interactive, and taking bottle or fluids well.”

• “Well hydrated, nontoxic, and no evidence of trauma, sepsis, meningitis, or distress.”

• “Alert, good tone, moving all extremities.”

• “Child appropriately cries but can be consoled by caregivers.”

This chapter demonstrates how to take a systematic approach to the evaluation of infants and toddlers in the ED to develop a comprehensive diagnostic and therapeutic plan by using three examples of different clinical manifestations: a crying infant, an infant or toddler with altered level of consciousness, and a vomiting infant or toddler.

The Crying Infant

“Birds fly and babies cry”

—Marc Weissbluth, pediatrician ⁶

Perspective

One of the most challenging aspects of pediatric emergency care is managing an infant with the nonspecific symptom of acute, excessive crying. Infants are not able to vocalize complaints, and crying is the primary mode of communication until language development. According to Brazelton, most babies will cry between and 3 hours per day in the first 3 months of life, with the peak occurring at approximately 6 weeks.⁷ By the time that parents bring their crying infant or toddler to the ED, they are often exhausted from attempts to console the child. In such circumstances, the EP must be able to distinguish between relatively benign conditions, such as colic, and severe, life-threatening illnesses, such as meningitis. An orderly approach to infants with excessive unexplained crying will allow the EP to diagnose the occasional severe illness and provide guidance to the caregivers.

Epidemiology

The prevalence of early excessive crying (e.g., >3 hours) in infants younger than 3 months has been estimated at 8% to 29%, but it may persist for months longer in up to 40% of these children.⁸ However, there is no accurate estimate of the incidence of excessive crying secondary to illness because almost every disease process can be accompanied by the symptom of crying. As infants grow and expand their repertoire for expressing specific needs, excessive crying is less frequently voiced as a primary complaint by caregivers.