The Fussy Infant

Background

It should be expected that the neonatal period is wrought with tears and crying – and not just from the proud parents. Interpreting a new infant’s cry is a challenge that many parents, new and experienced, face.  From hunger to soiled diapers to simply wanting to be cuddled, these cries may be benign.  According to Tintinalli, most neonates will exhibit varying degrees and periods of crying, with total crying time in a day increasing after birth and peaking around 3-5 months of age1. However, from time to time, a concerned parent may end up in the emergency department unable to console their infant, and it will be the job of the emergency physician to perform a thorough examination to determine if there is a more sinister source.

History pointers

To point you in the right direction, here are some questions you may consider asking (certainly not an exhaustive list!):

  • Birth history? Include prenatal history from the mother. Inquire about GBS status and if mother had any active herpes lesions during a vaginal delivery.
  • Frequency of crying (acute vs chronic)
  • Attempts to console
  • Feeding history, growth, urine and stool output
  • Fever at home? Vaccination status? Sick contacts/exposures? Presence of a fever and post-gestational age will change your work-up!
  • Breathing patterns, with or without apnea, skin color changes
  • Traumatic injury (Accidental or non-accidental)

Expanded Differential 

Many sources site IT CRIES as a useful mneumonic2. An expanded version is TIM’S CRIES3.

T – trauma (accidental and nonaccidental), tumor

I – infections (otitis media, herpes stomatitis, thrush, UTI, meningitis to name a few)

M – maternal / parental stress and anxiety, metabolic (hypoglycemia)

S – strangulation (hair / fiber tourniquet)

C – cardiorespiratory disease

R – reflux, medication reaction, reaction to formula, rectal (anal fissure), rash (diaper rash)

I – intracranial hypertension, immunizations, intolerance of lactose or cow’s milk allergy

E – eye (corneal abrasion, foreign body)

S – surgical (volvulus, intussusception, inguinal hernia, testicular torsion)

 

hair Example of Hair Tourniquet

Source: en.wikipedia.org/wiki/Hair_tourniquet#/media/File:Hairtournequet.JPG

ED Evaluation

The above causes of the fussy infant should be ruled out before giving the diagnosis of something such as colic, which should only be a diagnosis of exclusion. The official diagnosis of colic can be remembered in relation to the number “3”: occurs from 3 weeks to 3 months old, 3 hours per day, 3 days per week, for 3 weeks2. For a thorough exam, diligently evaluate the infant from head to toe.  As indicated based on your physical exam, including blood work, imaging, urinalysis, fluorescein to evaluate for corneal abrasion.  One study suggested that all afebrile infants within the first few months of life with this complaint should undergo urinalysis3.  No single approach is indicated in all infants4. Many parents may insist that the fussiness is related to gastrointestinal symptoms, however it is not recommended to tell parents to switch formula or to stop breastfeeding5 

Recommendations 

Parents will often want a solution to soothe the fussy infant. If there are no significant findings on exam, and you have deemed the infant stable for discharge home, there are a few tips and tricks that have been outlined in parenting books that may be of benefit to your patient’s worried parents.  While perhaps anecdotal and not necessarily evidence-based, behavioral changes may make the difference.  Dr. Harvey Karp, a pediatrician and child development expert, penned a parenting guide that outlines the 5 S’s:

Swaddle: wrap the baby in a loose, thin blanket or pre-made swaddle blanket for snug arms and loose hips.  This is best for fussiness and sleep.

Side or Stomach Position: Do not forget that the back is safest for sleep (Back To Sleep), but holding a baby towards your body in the side or stomach position may calm them.

Shush:  Saying “shush” may mimic the sounds they heard while in the womb, a comforting noise.

Swing: Life in the womb was full of movements, so gently swinging the infant (NOT shaking!) in fast, tiny motions may provide comfort.

Suck: Don’t forget the pacifier!

This blog on infantile colic lists other behavioral changes that may calm the infant, such as establishing regular routines, avoiding excessive stimulation, carrying the infant in a sling, respond to the infant’s cues before baby gets too worked up, and allow for parental respite by letting someone else hold the infant when crying.

Summary

Our job in the emergency department when evaluating the fussy infant is to rule out significant life-threats to the infant, and treat emergent conditions. Colic is a diagnosis of exclusion, once a more thorough list of differentials has been considered.  If there are no abnormal findings, parents may need reassurance and guidance for at-home care, which may include behavioral changes and the 5 S’s.  Close follow up with the infant’s pediatrician is recommended

 

Resources:

  1. Doan QH, Kissoon N. Neonatal Emergencies and Common Neonatal Problems. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016
  2. The Fussy Infant. PEM Playbook. March 1, 2018. http://pemplaybook.org/podcast/the-fussy-infant/
  3. Friedman SB et al. The crying infant: diagnostic testing and frequency of serious underlying disease. Pediatrics. 2009; 123(3):841-8
  4. Baby Tim’s Cries. Life in the Fast Lane. November 6, 2012. https://lifeinthefastlane.com/pediatric-perplexity-009/
  5. Infantile Colic. NUEM Blog, Emergency Medicine Resident Educations. September 19, 2016. http://www.nuemblog.com/blog/infantile-colic
  6. Fox, Sean. Inconsolable Infant. Pediatric EM Morsels. June 25, 2015. https://pedemmorsels.com/inconsolable-infant/

-Author: Alexis Cates D.O PGY 4

Twitter: @acates

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