pediatrics
Crying
Evaluation of Crying
History of present illnessfocuses on onset of crying, duration, response to attempts to console, and frequency or uniqueness of episodes. Parents should be asked about associated events or conditions, including recent immunizations, trauma (eg, falls), interaction with a sibling, infections, drug use, and relationship of crying with feedings and bowel movements. Review of systemsfocuses on symptoms of causative disorders, including constipation, diarrhea, vomiting, arching of back, explosive stools, and bloody stools (gastrointestinal disorders); fever, cough, wheezing, nasal congestion, and difficulty breathing (respiratory infection); and apparent pain during bathing or changing (trauma). Past medical historyshould note previous episodes of crying and conditions that can potentially predispose to crying (eg, history of heart disease, developmental delay). Examination begins with a review of vital signs, particularly for fever and tachypnea. Initial observation assesses the infant or child for signs of lethargy or distress and notes how the parents are interacting with the child. The infant or child is undressed and observed for signs of respiratory distress (eg, superclavicular and subcostal retractions, cyanosis). The entire body surface is inspected for swelling, bruising, and abrasions. Auscultatory examination focuses on signs of respiratory infection (eg, wheezing, crackles, decreased breath sounds) and cardiac compromise (eg, tachycardia, gallop, holosystolic murmur, systolic click). The abdomen is palpated for signs of tenderness. The diaper is removed for examination of the genitals and anus to look for signs of Testicular Torsion (eg, red-ecchymotic scrotum, pain on palpation), hair tourniquet on the penis, inguinal hernia (eg, swelling in the inguinal region or scrotum), and anal fissures. Extremities are examined for signs of fracture (eg, swelling, erythema, tenderness, pain with passive motion). Fingers and toes are checked for hair tourniquets. The ears are examined for signs of trauma (eg, blood in the canal or behind the tympanic membrane) or infection (eg, red, bulging tympanic membrane). The corneas are stained withfluoresceinand examined with a blue light to rule out corneal abrasion, and the fundi are examined with an ophthalmoscope for signs of hemorrhage. (If retinal hemorrhages are suspected, examination by an ophthalmologist is advised.) The oropharynx is examined for signs of thrush or oral abrasions. The skull is gently palpated for signs of fracture. The following findings are of particular concern: Respiratory distress Bruising and abrasions Extreme irritability Fever and inconsolability Fever in an infant≤8 weeks of age A high index of suspicion is warranted when evaluating crying. Parental concern is an important variable. When concern is high, the clinician should be wary even when there are no conclusive findings because the parents may be reacting subconsciously to subtle but significant changes. Conversely, a very low level of parental concern, particularly if there is lack of parental interaction with the infant or child, can indicate a bonding problem or an inability to assess and manage the child’s needs. Inconsistency of the history and the child’s clinical presentation should raise concerns about Overview of Child Maltreatment . It is helpful to distinguish the general area of concern. For example, with fever, the most likely etiology is infectious; respiratory distress without fever indicates possible cardiac etiology or pain. Abnormalities in stool history or abdominal pain during examination is consistent with a gastrointestinal etiology. Specific findings often suggest certain causes ( see Table: Some Causes of Crying ). The time frame is also helpful. Crying that has been intermittent over a number of days is of less concern than sudden, constant crying. Whether the cry is exclusive to a time of day or night is helpful. For example, recent onset of crying at night in an otherwise happy, healthy infant or child may be consistent with Separation anxiety or sleep association issues. The character of the cry is also revealing. Parents frequently can distinguish a cry that is painful in character from a frantic or scared cry. It is also important to determine the level of acuity. An inconsolable infant or child is of more concern than an infant or child who is well-appearing and consolable in the office. Testing is targeted at the suspected cause ( see Table: Some Causes of Crying ) and particular attention is paid to potential life threats, unless the history and physical examination are sufficient for diagnosis. When there are few or no specific clinical findings and no testing is immediately indicated, close follow-up and reevaluation are appropriate. 