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Assessment and Evaluation of the High Risk Neonate: The NICU Network Neurobehavioral Scale
Published on: August 25, 2014
The infant with acute, unexplained, excessive crying
1Department of Pediatrics, University of Colorado School of Medicine, Denver.
Insights
Excessive infant crying often signals serious conditions, requiring thorough physical exams for diagnosis. Infants who stop crying during assessment are less likely to have severe issues.
Area of Science:
- Pediatrics
- Emergency Medicine
Background:
- Infants presenting with unexplained excessive crying to the emergency department pose a diagnostic challenge.
- A significant percentage of these cases are ultimately diagnosed with serious underlying conditions.
Purpose of the Study:
- To evaluate the diagnostic yield of history and physical examination in infants with unexplained excessive crying.
- To identify predictors of serious pathology in this patient population.
Main Methods:
- Retrospective review of 56 infants presenting with excessive crying over one year.
- Analysis of diagnostic clues from patient history and physical examination findings.
- Correlation of crying cessation during assessment with final diagnosis.
Main Results:
- 61% of final diagnoses were considered serious.
- History provided diagnostic clues in 20%; physical examination was diagnostic in 41% and provided clues in 13%.
- Persistent crying post-initial examination predicted serious causes, while crying cessation suggested benign etiology.
Conclusions:
- A comprehensive physical examination is crucial for diagnosing serious causes of excessive infant crying.
- Persistent crying in the emergency department is a key indicator of potential serious pathology.
- A stepwise diagnostic approach is recommended for infants with unexplained crying.
Abstract:
This study describes 56 infants who presented to the Emergency Department of The Children's Hospital of Denver during a 1-year period with an episode of excessive, prolonged crying, without fever and without a cause that was apparent to the parents. The final diagnoses included a broad array of conditions, of which 61% were considered serious. The history provided clues to the final diagnosis in 20% of cases. Physical examination revealed the final diagnosis in 41% and provided clues to the diagnosis in another 13%. Accurate diagnosis requires a thorough physical examination, which should include careful skin inspection underneath all clothing, palpation of all large bones, fluorescein staining of the cornea, eversion of eyelids, rectal examination, retinal examination, and thorough neurologic examination. "Screening" laboratory tests, except for urinalysis and urine culture, were of little help. This study indicates that for those patients in whom the physical examination is not diagnostic, the persistence of excessive crying after the initial examination predicts the presence of a serious cause. Those infants who cease crying before or during the initial assessment are unlikely to have a serious cause. Recommendations for a stepwise assessment are offered.
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