Rosen & Barkin's 5-Minute Emergency Medicine Consult (402 page)

• Constipation
  
• Diarrhea
  
• Gastroenteritis
  
• Inflammatory Bowel Disease
  

CODES

• 306.4 Gastrointestinal malfunction arising from mental factors
  
• 564.1 Irritable bowel syndrome
  

BASICS

• Most children have some period of the day when they are most irritable, usually toward the evening:
  
  • Normal infant crying ranges from 1–4 hr by 6 wk of age.
    
  • During the 1st 6 mo of life, 1 mo olds have the highest prevalence of crying
    
• Irritability is based on a comparison with the child’s normal behavior pattern
  
• Colic is the most common cause of inconsolable crying in infants, occurring in as many as 25% of healthy children:
  
  • Episodes of paroxysmal screaming accompanied by drawing up knees and oftentimes passage of flatus
    
  • Usually begins at 2–3 wk and may continue through 12 wk
    
  • Diagnosis of exclusion
    

• Bites: Spider/insect bite
  
• Burn
  
• Cardiac (supraventricular tachycardia, congestive heart failure, aberrant left coronary artery, coarctation of the aorta, endocarditis, myocarditis)
  
• Child abuse
  
• Corneal abrasion/foreign body (eyelash) in eye
  
• Diaper pin
  
• Diphtheria, pertussis, and tetanus (DPT) and other vaccine reactions
  
• Endocrine/metabolic (inborn errors of metabolism, metabolic acidosis, hypernatremia, hypoglycemia, hypocalcemia, hyperthyroid—direct or by transplacental passage of maternal thyroid stimulating immunoglobulins)
  
• Foreign body, fracture, tourniquet (hair around digit or penis)
  
• Gl (gastroenteritis, colic, gastroesophageal reflux, esophagitis, volvulus, malrotation constipation, cow’s milk protein intolerance, anal fissure, intussusception, appendicitis)
  
• Genitourinary (incarcerated hernia, testicular torsion, genital tourniquets, urinary retention)
  
• Iron deficiency/anemia
  
• Medications/toxins: Aspirin, antihistamines, atropine, adrenergics, home remedies, new prescription, mercury)
  
• Meningitis
  
• Minor acute infections (upper respiratory infection, otitis media, thrush, gingivostomatitis)
  
• Neurologic (increased intracranial pressure: Mass, hydrocephalus, intracranial hemorrhage, hematoma—subdural, epidural, skull fracture)
  
• Osteomyelitis
  
• Parental anxiety
  
• Pneumonia
  
• Sickle cell crisis
  
• Splinter
  
• Teething
  
• Trauma
  
• UTI
  
• Vascular
  

DIAGNOSIS

• Vital signs
  
• Chief complaint
  
• Chronology of events
  

Obtain complete history (including neonatal history) and information regarding routine feeding, crying.

• Assess vital signs including rectal temperature and pulse oximetry.
  
• Measure and plot for percentiles: Height, weight, and head circumference.
  
• Perform a thorough physical exam with infant completely undressed.
  

This is usually directed by a comprehensive history and physical exam. Specific studies may be obtained.

• CBC, urinalysis, chemistries, and cultures as indicated by history and physical exam
  
• Stat blood glucose at bedside if indicated.
  
• Stool hemoccult test if GI signs or symptoms
  

• Chest radiograph to exclude cardiopulmonary disease
  
• Skeletal survey, if indicated
  
• CT scan of the head, chest, etc. usually directed by history and physical exam
  
• Contrast radiograph studies such as barium enema for specific indications
  

• Fluorescein eye exam
  
• ECG
  

See etiology above. It is essential to distinguish benign, self-limited conditions from those that might be life threatening.

TREATMENT

As determined by history, physical exam, and lab studies

• Manage underlying conditions; stabilize airway, breathing, and circulation (ABCs).
  
• Immediate removal of hair tourniquets and/or splinters
  

• Initial evaluation of the child focusing on parent–child interaction and then on potential underlying conditions
  
• Colic responds to soothing, rhythmic activities, avoiding stimulants (coffee, cola), minimizing daytime sleep:
  
  • Soy or hydrolyzed casein formula may be transiently beneficial.
    
  • Parents must reduce stress
    
  • No proven pharmacologic therapy
    
  • Probiotics may be useful
    
• Support, empathy, close follow-up
  
• Prolonged observation of the child is usually appropriate.
  

Dependent on the underlying condition

Dependent on the underlying condition

Dependent on the underlying condition

FOLLOW-UP

• Life-threatening underlying condition
  
• Significant parental stress secondary to crying infant
  

• No serious condition
  
• Functional and supportive family
  
• Excellent follow-up is essential; parents must feel that their observations and concerns are not being ignored. Close follow-up and ongoing observation are mandatory to reevaluate the child and provide support to the family.
  

Determined by specific specialty related issues

Long-term follow-up strongly recommended

• Address life-threatening/serious causes of irritability first:
  
  • Cardiovascular: Supraventricular tachycardia, congestive heart failure, endocarditis/myocarditis
    
  • Neurologic: Subdural/epidural, meningitis, intracranial hemorrhage, increased intracranial pressure, skull fracture
    
  • Gl: Volvulus, intussusception, appendicitis, peritonitis
    
  • Metabolic: Metabolic acidosis, electrolyte disturbances
    
  • Genitourinary: UTI, torsion of testis, incarcerated hernia
    
  • Pulmonary: Foreign body, pneumothorax, pneumonia
    
  • Dermatologic: Strangulated digit
    
  • Toxicologic: Toxic ingestion, immunization reaction
    
  • Trauma
    
  • Ophthalmologic: Corneal abrasion, glaucoma
    
  • Other: Child abuse, transplacental passage of maternal medications that may cause irritability
    
• Detailed history and complete physical exam in the noncritically ill child is crucial before obtaining any lab or radiologic studies
  

• Benjamin JS, Chong E, Ramayya MS. A preterm, female newborn with tachycardia, hypertension, poor weight gain, and irritability.
  Clin Pediatr (Phila).
  2012;51(10):994–997.
  
• French LK, Campbell J, Hendrickson RG. A hypertensive child with irritability and a rash.
  Pediatr Emerg Care
  . 2012;28(6):581–583.
  
• Garrison MM, Christakis DA. A systematic review of treatments for infant colic.
  Pediatrics
  . 2000;106(1 pt 2):184–190.
  
• Herman M, Le A. The crying infant.
  Emerg Med Clin North Am
  . 2007;25:1137–1159.
  
• Hiscock H, Jordan B. 1. Problem crying in infancy.
  Med J Aust
  . 2004;181(9):507–512.
  
• Pawel BB, Henretig FM. Crying and colic in early infancy. In: Fleisher GR, Ludwig S, eds.
  Textbook of Pediatric Emergency Medicine
  . 6th ed. Philadelphia, PA: Lippincott; 2010.
  
• Swischuk LE. Irritable infant and left lower extremity pain.
  Pediatr Emerg Care
  . 1997;13(2):147–148.
  
• Ward TR, Falconer JA, Craven JA. An irritable infant and the runaway redback: An instructive case.
  Case Rep Emerg Med
  . 2011;2011:125740