Alexandra Leader, MD

Case

A previously healthy 4-month-old infant was brought to the ED late on a Sunday afternoon by his father, who reported that his son had been crying hysterically since the previous evening. The father stated that the infant was well until he awoke crying in his crib around midnight. Since then, the baby had not slept for more than 20 minutes uninterrupted and had not breastfed as usual due to the persistent crying. According to the father, the patient had been a “good baby” since birth, eating well and even sleeping through the night for the past month; specifically, his son’s continual crying was not typical of his usual behavior.

There was no known trauma, fever, congestion, cough, vomiting, or diarrhea at home, and the father confirmed the patient had been making wet diapers throughout the day. The baby had received his 4-month vaccines and, according to his pediatrician, had been following a normal growth pattern.           

As the patient’s father related his son’s history, he appeared exhausted and extremely anxious, pacing the room as he spoke and trying unsuccessfully to quiet the baby. He stated that the patient’s mother, who was at home in bed with mastitis, was afraid their son had become ill because she had breastfed him while she had a fever. The father confessed that he was concerned that their older son, a rambunctious 2-year-old who shares the same room as the patient, may have accidentally done something to harm the baby unbeknownst to him or his wife.

In relating the history, the infant’s father was almost tearful as he admitted that he and his wife felt completely overwhelmed and helpless that they were not able to soothe or comfort the patient.

Overview

While often the healthiest of patients seen in the ED, infants with unexplained, prolonged crying are challenging to evaluate and discharge—especially in the care of distraught parents. The following review is intended to provide a basis for understanding the scope of normal crying in infants, how and if to diagnose infantile colic in the ED, and how to avoid missing common pathology requiring acute management in the infant with new, unexplained crying.

Normal Crying: How Much Is Too Much?

During the first 3 to 4 months of life, infants cry more than at any other time. Developmental pediatrician Harvey Karp, MD, dubs the first 3 months of an infant’s life as the “fourth trimester,” during which period the baby yearns for the calming acoustic and tactile sensations of the womb. He notes that crying in this fourth trimester is merely a response to the abruptly distinct stimulation of the outside world.¹ Just as each baby tolerates these new sensations differently after birth, and is soothed in her or his own measure, each parent too has a different perception and tolerance of an infant’s crying—making for a clinical parameter that is difficult to clearly assess.

What, then has been established as the upper limit of normal for crying in infancy? In the 1960s, Brazelton’s studies defined normal crying as 1 hour and 45 minutes per day at age 2 weeks; 2 hours and 45 minutes at age 6 weeks; and less than 1 hour per day by age 12 weeks.² A more recent meta-analysis reinforces Brazelton’s criteria, indicating that the mean duration of crying is approximately 2 hours per day during the first 6 weeks of life and decreasing to a daily mean of 72 minutes by age 10 to 12 weeks.³

Infantile Colic

As the caregiver’s report of the duration of crying is often subjective, more emphasis has been placed on evaluating patterns of newborn crying by defining what is excessive. Infantile colic, or excessive crying in an otherwise healthy baby, is classically defined as fussing or crying lasting more than 3 hours per day and occurring on more than 3 days per week in a baby who is gaining weight and is otherwise well.⁴ Severe colic is further described as the persistence of the crying pattern for more than 3 weeks. When using this “rule of 3s,” excessive crying is estimated to be present in 1.5% to 11.9% of the infant population. There are, however, many other definitions of what constitutes excessive crying, including the more inclusive and subjective definition of colic as “intermittent, unexplained crying during the first 3 months of life that reaches a point where the parents complain about it.”⁵

Depending upon the definition utilized, as many as 43% of infants experience excessive crying.⁶ What is more uniformly accepted in the extensive literature on infantile colic is the observation that crying because of colic is concentrated during the hours of 3:00 pm to 11:00 pm and is associated with infant behaviors such as clenched fists, back-arching, passing gas, grimacing, and flexing legs, as well as with maternal anxiety.^1,2,7,8

Diagnostic Certainty and Setting

Infantile colic is a diagnosis that is made retrospectively in the setting of an otherwise healthy infant who is growing and developing appropriately, and whose excessive crying ultimately resolves without medical intervention. Since colic is difficult to diagnose from any single medical encounter in the ED, it must be a diagnosis reached after excluding other possible causes.

Soothing the Colicky Infant

Extensive parental reassurance is required prior to discharging a colicky infant home—with the understanding that by the time of presentation in the ED, most parents have already exhausted their parental soothing abilities and personal coping mechanisms. Moreover, the typical physician’s promise that “this too, shall pass” is just not a sufficient addition to the parental armamentarium to manage their baby’s colic. Parents instead must be given effective techniques to calm colicky infants. Karp enumerates the following alliterative “5 Ss” guideline for soothing and calming fussy infants:

(1) Swaddling;
(2) Side/Stomach position (not while sleeping);
(3)“Shhhhhing” to provide a soothing sound that recalls the womb;
(4) Swinging the baby rhythmically in parents’ arms; and
(5) Sucking, either a pacifier or the mother’s breast.¹

Equally important guidance prior to discharge from the ED is to inform parents that if they become overwhelmed by the baby’s fussing, it is always better to place an infant in the crib and let him or her cry alone for some time rather than allowing frustration to build with the baby in one's arms and increasing the potential of unintentionally harming the infant.

The “Don’t Miss” Differential Diagnoses

Whereas, as much as 43% of the infant population may experience excessive crying, only approximately 5% of infants with colic have underlying organic disease.⁸ The emergency physician (EP) is responsible for identifying this 5% when these infants present to the ED. A useful way to focus the initial evaluation of excessive crying is to determine the chronicity of the infant’s symptoms. To begin with, it is important to identify those babies who are in the ED merely because they have finally overwhelmed their parents with recurrent, intermittent bouts of prolonged crying despite being otherwise healthy and maintaining eating and sleeping patterns largely unaffected by crying. These are the infants who, after a thorough physical examination revealing none of the causes described below, should be swaddled, “shhhhhh’ed,” swung, suckled, and discharged with parental reassurance.

The EP, however, must be able to differentiate the classically colicky infant described above from the baby who has acutely developed unexplained crying and is at higher risk of serious disease or condition. In a study of afebrile infants experiencing an acute episode of excessive, prolonged crying, approximately 60% had an underlying disease process requiring management.⁹ Fortunately, many of these diagnoses can be made by an astute physical examination. In addition to evaluating infants for the most typical causes of new, prolonged crying, such as otitis media and anal fissures, the following common diagnoses should be clinically excluded in all infants presenting to the ED with acute, unexplained crying.   

Corneal Abrasion

Performing a comprehensive eye examination on an inconsolable infant is not an easy task. However, corneal abrasions and foreign bodies in the eye are notorious causes of acute, excessive crying in infants—ones that are not always accompanied by conspicuous signs such as lacrimation or conjunctival injection.¹⁰

Fluorescein staining of both corneas should be performed to evaluate for a corneal abrasion. The infant’s eyelids should also be everted to look for retained foreign bodies, especially when vertical corneal abrasions have been visualized with fluorescein staining. Administering a topical ophthalmic anesthetic prior to fluorescein staining is advisable; this can be both therapeutic and diagnostic since resolution of crying after numbing the infant’s affected eye supports the diagnosis of corneal abrasion or foreign body.

Infants with corneal abrasions can be managed with a topical antibiotic ointment and 24-hour follow-up. Of note, recent studies indicate that asymptomatic corneal abrasions are extremely common in the infant period, suggesting that physicians should be careful to consider and exclude other potential causes of acute, excessive crying before attributing the symptoms to a corneal abrasion identified on examination.¹¹

Hair Tourniquet Syndrome

Also referred to as hair thread tourniquet syndrome, the circumferential constriction of an infant’s appendage with hair, thread, or another fine material may present with the chief complaint of crying. Hair tourniquets most often involve the toes, followed by the fingers and external genitalia, and, if unrecognized or untreated, will lead to ischemia and necrosis of the distal tissue. Sleepwear that encloses the feet is a strong

risk factor for toe tourniquets, and the use of mittens is similarly linked to finger tourniquets.^7,12

The crying or irritable infant merits a thorough examination of all digits and external genitalia in search of constricting bands and resultant tissue swelling. If the tourniquet has gone unnoticed over time, severe swelling, embedding of the thread, or re-epithelialization of the skin over lacerated tissue may obscure the band and make simple removal impossible. In cases when the constricting band cannot be directly unwound, treatment options for a hair tourniquet include application of a depilatory agent (eg, Nair), which has been shown to effectively dissolve the hair within 8 minutes.¹³ If a severe laceration is present and the thread cannot be removed by unwinding, the depilatory agent should not be applied to open tissue; instead, the clinician should perform a dorsal incision of the toe or finger to remove the constricting material in its entirety.

Testicular Torsion

Testicular torsion is a common urologic emergency in the male pediatric population, with up to 12% of all cases occurring within the first year of life. It should be considered in any infant who develops acute, prolonged, unexplained crying. Eighty-five percent of infants with torsion between 1 and 12 months old will present with irritability, and 92% will present with a tender scrotal or inguinal mass¹⁴ that may go unnoticed by the parents. This possibility alone is a compelling reason to remove the diaper of an infant with prolonged crying and to perform a thorough physical examination.

While testicular deformity or a high-riding testicle can be difficult to assess on a crying baby, any scrotal enlargement, tenderness, or color change merits an emergent urology consult—and likely ultrasound imaging with Doppler sonography. Efficient and rapid management of infants with testicular torsion is essential as the testicular salvage rate is historically very poor in this population.¹⁵

Inguinal Hernia

The reported incidence of pediatric inguinal hernia is between 0.8% and 4.4%, with most patients presenting with a chief complaint of inguinal swelling. Inguinal hernias alone are symptomatic in up to 25% of infants and may present as prolonged crying.¹⁶ In these cases, inguinal hernia surgery is usually scheduled as an elective outpatient procedure. Serious issues arise when the bowel becomes edematous and incarcerated in the hernial sac, which can lead to ischemic necrosis and intestinal perforation, intestinal obstruction, and gonadal necrosis.

More than half of all cases of pediatric incarcerated hernias occur within the first 6 months of life. Infants younger than age 12 months—especially neonates—have a more severe and a higher incidence of complications related to incarcerated inguinal hernias than the rest of the pediatric population. In a recent study, one third of newborn patients were diagnosed with incarceration as their initial presentation of an inguinal hernia.¹⁷ This is another reason to remove the patient’s diaper and perform a complete physical examination on any infant presenting with acute, unexplained crying. An incarcerated inguinal hernia will likely be identified as a tender, firm, inguinal or scrotal mass with overlying swelling or discoloration and is a surgical emergency if it cannot be reduced manually.

Nonaccidental Trauma

Emergency physicians must maintain a high index of suspicion for nonaccidental trauma in pediatric patients. Studies demonstrate that 95% of serious intracranial injuries and 64% of all head injuries in infants younger than age 12 months are the result of physical abuse. Equally discouraging is the finding that as many as 75% of child abuse cases presenting to EDs are unrecognized.^18,19 Infants presenting with excessive crying have elevated risk for nonaccidental trauma both because their crying may be a result of injuries sustained from physical abuse and also because their prolonged crying itself may have been a precipitating factor in nonaccidental trauma.

Stress predisposes a caregiver to child abuse and is particularly important to identify when evaluating an infant with prolonged crying and also when providing guidance to the parents of a child with symptoms of infantile colic. Additional signs of possible nonaccidental trauma include an inconsistent history, a delay in seeking medical care, inappropriate affect of the caregiver, and an injury that is not well explained by the caregiver’s history or is incompatible with the developmental stage of the child.

Other Causes

While there are no specific laboratory tests required for the diagnosis of the abovementioned common neonatal causes of acute, prolonged crying, the EP must always consider life-threatening conditions in the inconsolable or irritable infant, including dehydration, early shock, meningitis, and a surgical abdomen. The pursuit of an appropriate workup for these diseases, accompanied by an awareness that infants may present atypically (eg, hypothermic instead of febrile) will often lead to comprehensive laboratory studies.

The EP additionally cannot undervalue the importance of trending vital signs and should never assume that tachycardia and tachypnea are due to crying alone. The onus is on the EP to consider and exclude serious illness, and nonemergent causes of prolonged crying should not be diagnosed in the setting of lethargy or poor feeding without a thorough workup. Any infant who is crying too much and eating too little per parental history is an infant who should be screened for possible underlying serious disease.

Case Conclusion

The patient in this case was found to be afebrile, tachycardic, tachypneic, and with a normal oxygen saturation while crying inconsolably on initial examination. Upon removal of the infant’s closed-footed pajamas, the distal second toe of his right foot was noted to be markedly swollen and erythematous. The EP recognized the presence of a hair tourniquet but was unable to unwind the constricting hair due to the small size of the infant’s toe and extent of tissue swelling. Topical anesthetic cream was first applied to the toe and, as there was no visible laceration of the skin, depilatory cream was subsequently applied to the tourniquet. After 10 minutes, the toe was rubbed and rinsed with water and the hair tourniquet dissolved. There was significant improvement in tissue swelling and color within 1 hour of removal of the constricting band. The affected toe demonstrated adequate capillary refill and no sign of persistent vascular compromise. The patient’s crying subsided and his vital signs and remainder of his physical examination were normal.

Since there was evidence of superficial skin breakdown at the site of the hair tourniquet, the patient’s father was instructed to apply topical antibiotic ointment to the site and to follow-up with the patient’s pediatrician in 24 hours. Of note, the father stated that the infant’s mother had been experiencing significant postpartum hair loss recently and that they would now be careful to remove loose hair from the baby’s clothing and bedding—especially when dressing him in closed-footed pajamas or mittens. 

Dr Leader is a fellow, department of pediatric emergency medicine, Eastern Virginia Medical School, Norfolk, Virginia. Dr Clingenpeel is a fellowship director, pediatric emergency medicine, and associate professor of pediatrics, Eastern Virginia Medical School, Norfolk.

Case

A previously healthy 4-month-old infant was brought to the ED late on a Sunday afternoon by his father, who reported that his son had been crying hysterically since the previous evening. The father stated that the infant was well until he awoke crying in his crib around midnight. Since then, the baby had not slept for more than 20 minutes uninterrupted and had not breastfed as usual due to the persistent crying. According to the father, the patient had been a “good baby” since birth, eating well and even sleeping through the night for the past month; specifically, his son’s continual crying was not typical of his usual behavior.

There was no known trauma, fever, congestion, cough, vomiting, or diarrhea at home, and the father confirmed the patient had been making wet diapers throughout the day. The baby had received his 4-month vaccines and, according to his pediatrician, had been following a normal growth pattern.           

As the patient’s father related his son’s history, he appeared exhausted and extremely anxious, pacing the room as he spoke and trying unsuccessfully to quiet the baby. He stated that the patient’s mother, who was at home in bed with mastitis, was afraid their son had become ill because she had breastfed him while she had a fever. The father confessed that he was concerned that their older son, a rambunctious 2-year-old who shares the same room as the patient, may have accidentally done something to harm the baby unbeknownst to him or his wife.

In relating the history, the infant’s father was almost tearful as he admitted that he and his wife felt completely overwhelmed and helpless that they were not able to soothe or comfort the patient.

Overview

While often the healthiest of patients seen in the ED, infants with unexplained, prolonged crying are challenging to evaluate and discharge—especially in the care of distraught parents. The following review is intended to provide a basis for understanding the scope of normal crying in infants, how and if to diagnose infantile colic in the ED, and how to avoid missing common pathology requiring acute management in the infant with new, unexplained crying.

Normal Crying: How Much Is Too Much?

During the first 3 to 4 months of life, infants cry more than at any other time. Developmental pediatrician Harvey Karp, MD, dubs the first 3 months of an infant’s life as the “fourth trimester,” during which period the baby yearns for the calming acoustic and tactile sensations of the womb. He notes that crying in this fourth trimester is merely a response to the abruptly distinct stimulation of the outside world.¹ Just as each baby tolerates these new sensations differently after birth, and is soothed in her or his own measure, each parent too has a different perception and tolerance of an infant’s crying—making for a clinical parameter that is difficult to clearly assess.

What, then has been established as the upper limit of normal for crying in infancy? In the 1960s, Brazelton’s studies defined normal crying as 1 hour and 45 minutes per day at age 2 weeks; 2 hours and 45 minutes at age 6 weeks; and less than 1 hour per day by age 12 weeks.² A more recent meta-analysis reinforces Brazelton’s criteria, indicating that the mean duration of crying is approximately 2 hours per day during the first 6 weeks of life and decreasing to a daily mean of 72 minutes by age 10 to 12 weeks.³

Infantile Colic

As the caregiver’s report of the duration of crying is often subjective, more emphasis has been placed on evaluating patterns of newborn crying by defining what is excessive. Infantile colic, or excessive crying in an otherwise healthy baby, is classically defined as fussing or crying lasting more than 3 hours per day and occurring on more than 3 days per week in a baby who is gaining weight and is otherwise well.⁴ Severe colic is further described as the persistence of the crying pattern for more than 3 weeks. When using this “rule of 3s,” excessive crying is estimated to be present in 1.5% to 11.9% of the infant population. There are, however, many other definitions of what constitutes excessive crying, including the more inclusive and subjective definition of colic as “intermittent, unexplained crying during the first 3 months of life that reaches a point where the parents complain about it.”⁵

Depending upon the definition utilized, as many as 43% of infants experience excessive crying.⁶ What is more uniformly accepted in the extensive literature on infantile colic is the observation that crying because of colic is concentrated during the hours of 3:00 pm to 11:00 pm and is associated with infant behaviors such as clenched fists, back-arching, passing gas, grimacing, and flexing legs, as well as with maternal anxiety.^1,2,7,8

Diagnostic Certainty and Setting

Infantile colic is a diagnosis that is made retrospectively in the setting of an otherwise healthy infant who is growing and developing appropriately, and whose excessive crying ultimately resolves without medical intervention. Since colic is difficult to diagnose from any single medical encounter in the ED, it must be a diagnosis reached after excluding other possible causes.

Soothing the Colicky Infant

Extensive parental reassurance is required prior to discharging a colicky infant home—with the understanding that by the time of presentation in the ED, most parents have already exhausted their parental soothing abilities and personal coping mechanisms. Moreover, the typical physician’s promise that “this too, shall pass” is just not a sufficient addition to the parental armamentarium to manage their baby’s colic. Parents instead must be given effective techniques to calm colicky infants. Karp enumerates the following alliterative “5 Ss” guideline for soothing and calming fussy infants:

(1) Swaddling;
(2) Side/Stomach position (not while sleeping);
(3)“Shhhhhing” to provide a soothing sound that recalls the womb;
(4) Swinging the baby rhythmically in parents’ arms; and
(5) Sucking, either a pacifier or the mother’s breast.¹

Equally important guidance prior to discharge from the ED is to inform parents that if they become overwhelmed by the baby’s fussing, it is always better to place an infant in the crib and let him or her cry alone for some time rather than allowing frustration to build with the baby in one's arms and increasing the potential of unintentionally harming the infant.

The “Don’t Miss” Differential Diagnoses

Whereas, as much as 43% of the infant population may experience excessive crying, only approximately 5% of infants with colic have underlying organic disease.⁸ The emergency physician (EP) is responsible for identifying this 5% when these infants present to the ED. A useful way to focus the initial evaluation of excessive crying is to determine the chronicity of the infant’s symptoms. To begin with, it is important to identify those babies who are in the ED merely because they have finally overwhelmed their parents with recurrent, intermittent bouts of prolonged crying despite being otherwise healthy and maintaining eating and sleeping patterns largely unaffected by crying. These are the infants who, after a thorough physical examination revealing none of the causes described below, should be swaddled, “shhhhhh’ed,” swung, suckled, and discharged with parental reassurance.

The EP, however, must be able to differentiate the classically colicky infant described above from the baby who has acutely developed unexplained crying and is at higher risk of serious disease or condition. In a study of afebrile infants experiencing an acute episode of excessive, prolonged crying, approximately 60% had an underlying disease process requiring management.⁹ Fortunately, many of these diagnoses can be made by an astute physical examination. In addition to evaluating infants for the most typical causes of new, prolonged crying, such as otitis media and anal fissures, the following common diagnoses should be clinically excluded in all infants presenting to the ED with acute, unexplained crying.   

Corneal Abrasion

Performing a comprehensive eye examination on an inconsolable infant is not an easy task. However, corneal abrasions and foreign bodies in the eye are notorious causes of acute, excessive crying in infants—ones that are not always accompanied by conspicuous signs such as lacrimation or conjunctival injection.¹⁰

Fluorescein staining of both corneas should be performed to evaluate for a corneal abrasion. The infant’s eyelids should also be everted to look for retained foreign bodies, especially when vertical corneal abrasions have been visualized with fluorescein staining. Administering a topical ophthalmic anesthetic prior to fluorescein staining is advisable; this can be both therapeutic and diagnostic since resolution of crying after numbing the infant’s affected eye supports the diagnosis of corneal abrasion or foreign body.

Infants with corneal abrasions can be managed with a topical antibiotic ointment and 24-hour follow-up. Of note, recent studies indicate that asymptomatic corneal abrasions are extremely common in the infant period, suggesting that physicians should be careful to consider and exclude other potential causes of acute, excessive crying before attributing the symptoms to a corneal abrasion identified on examination.¹¹

Hair Tourniquet Syndrome

Also referred to as hair thread tourniquet syndrome, the circumferential constriction of an infant’s appendage with hair, thread, or another fine material may present with the chief complaint of crying. Hair tourniquets most often involve the toes, followed by the fingers and external genitalia, and, if unrecognized or untreated, will lead to ischemia and necrosis of the distal tissue. Sleepwear that encloses the feet is a strong

risk factor for toe tourniquets, and the use of mittens is similarly linked to finger tourniquets.^7,12

The crying or irritable infant merits a thorough examination of all digits and external genitalia in search of constricting bands and resultant tissue swelling. If the tourniquet has gone unnoticed over time, severe swelling, embedding of the thread, or re-epithelialization of the skin over lacerated tissue may obscure the band and make simple removal impossible. In cases when the constricting band cannot be directly unwound, treatment options for a hair tourniquet include application of a depilatory agent (eg, Nair), which has been shown to effectively dissolve the hair within 8 minutes.¹³ If a severe laceration is present and the thread cannot be removed by unwinding, the depilatory agent should not be applied to open tissue; instead, the clinician should perform a dorsal incision of the toe or finger to remove the constricting material in its entirety.

Testicular Torsion

Testicular torsion is a common urologic emergency in the male pediatric population, with up to 12% of all cases occurring within the first year of life. It should be considered in any infant who develops acute, prolonged, unexplained crying. Eighty-five percent of infants with torsion between 1 and 12 months old will present with irritability, and 92% will present with a tender scrotal or inguinal mass¹⁴ that may go unnoticed by the parents. This possibility alone is a compelling reason to remove the diaper of an infant with prolonged crying and to perform a thorough physical examination.

While testicular deformity or a high-riding testicle can be difficult to assess on a crying baby, any scrotal enlargement, tenderness, or color change merits an emergent urology consult—and likely ultrasound imaging with Doppler sonography. Efficient and rapid management of infants with testicular torsion is essential as the testicular salvage rate is historically very poor in this population.¹⁵

Inguinal Hernia

The reported incidence of pediatric inguinal hernia is between 0.8% and 4.4%, with most patients presenting with a chief complaint of inguinal swelling. Inguinal hernias alone are symptomatic in up to 25% of infants and may present as prolonged crying.¹⁶ In these cases, inguinal hernia surgery is usually scheduled as an elective outpatient procedure. Serious issues arise when the bowel becomes edematous and incarcerated in the hernial sac, which can lead to ischemic necrosis and intestinal perforation, intestinal obstruction, and gonadal necrosis.

More than half of all cases of pediatric incarcerated hernias occur within the first 6 months of life. Infants younger than age 12 months—especially neonates—have a more severe and a higher incidence of complications related to incarcerated inguinal hernias than the rest of the pediatric population. In a recent study, one third of newborn patients were diagnosed with incarceration as their initial presentation of an inguinal hernia.¹⁷ This is another reason to remove the patient’s diaper and perform a complete physical examination on any infant presenting with acute, unexplained crying. An incarcerated inguinal hernia will likely be identified as a tender, firm, inguinal or scrotal mass with overlying swelling or discoloration and is a surgical emergency if it cannot be reduced manually.

Nonaccidental Trauma

Emergency physicians must maintain a high index of suspicion for nonaccidental trauma in pediatric patients. Studies demonstrate that 95% of serious intracranial injuries and 64% of all head injuries in infants younger than age 12 months are the result of physical abuse. Equally discouraging is the finding that as many as 75% of child abuse cases presenting to EDs are unrecognized.^18,19 Infants presenting with excessive crying have elevated risk for nonaccidental trauma both because their crying may be a result of injuries sustained from physical abuse and also because their prolonged crying itself may have been a precipitating factor in nonaccidental trauma.

Stress predisposes a caregiver to child abuse and is particularly important to identify when evaluating an infant with prolonged crying and also when providing guidance to the parents of a child with symptoms of infantile colic. Additional signs of possible nonaccidental trauma include an inconsistent history, a delay in seeking medical care, inappropriate affect of the caregiver, and an injury that is not well explained by the caregiver’s history or is incompatible with the developmental stage of the child.

Other Causes

While there are no specific laboratory tests required for the diagnosis of the abovementioned common neonatal causes of acute, prolonged crying, the EP must always consider life-threatening conditions in the inconsolable or irritable infant, including dehydration, early shock, meningitis, and a surgical abdomen. The pursuit of an appropriate workup for these diseases, accompanied by an awareness that infants may present atypically (eg, hypothermic instead of febrile) will often lead to comprehensive laboratory studies.

The EP additionally cannot undervalue the importance of trending vital signs and should never assume that tachycardia and tachypnea are due to crying alone. The onus is on the EP to consider and exclude serious illness, and nonemergent causes of prolonged crying should not be diagnosed in the setting of lethargy or poor feeding without a thorough workup. Any infant who is crying too much and eating too little per parental history is an infant who should be screened for possible underlying serious disease.

Case Conclusion

The patient in this case was found to be afebrile, tachycardic, tachypneic, and with a normal oxygen saturation while crying inconsolably on initial examination. Upon removal of the infant’s closed-footed pajamas, the distal second toe of his right foot was noted to be markedly swollen and erythematous. The EP recognized the presence of a hair tourniquet but was unable to unwind the constricting hair due to the small size of the infant’s toe and extent of tissue swelling. Topical anesthetic cream was first applied to the toe and, as there was no visible laceration of the skin, depilatory cream was subsequently applied to the tourniquet. After 10 minutes, the toe was rubbed and rinsed with water and the hair tourniquet dissolved. There was significant improvement in tissue swelling and color within 1 hour of removal of the constricting band. The affected toe demonstrated adequate capillary refill and no sign of persistent vascular compromise. The patient’s crying subsided and his vital signs and remainder of his physical examination were normal.

Since there was evidence of superficial skin breakdown at the site of the hair tourniquet, the patient’s father was instructed to apply topical antibiotic ointment to the site and to follow-up with the patient’s pediatrician in 24 hours. Of note, the father stated that the infant’s mother had been experiencing significant postpartum hair loss recently and that they would now be careful to remove loose hair from the baby’s clothing and bedding—especially when dressing him in closed-footed pajamas or mittens. 

Dr Leader is a fellow, department of pediatric emergency medicine, Eastern Virginia Medical School, Norfolk, Virginia. Dr Clingenpeel is a fellowship director, pediatric emergency medicine, and associate professor of pediatrics, Eastern Virginia Medical School, Norfolk.

Case

A previously healthy 4-month-old infant was brought to the ED late on a Sunday afternoon by his father, who reported that his son had been crying hysterically since the previous evening. The father stated that the infant was well until he awoke crying in his crib around midnight. Since then, the baby had not slept for more than 20 minutes uninterrupted and had not breastfed as usual due to the persistent crying. According to the father, the patient had been a “good baby” since birth, eating well and even sleeping through the night for the past month; specifically, his son’s continual crying was not typical of his usual behavior.

There was no known trauma, fever, congestion, cough, vomiting, or diarrhea at home, and the father confirmed the patient had been making wet diapers throughout the day. The baby had received his 4-month vaccines and, according to his pediatrician, had been following a normal growth pattern.           

As the patient’s father related his son’s history, he appeared exhausted and extremely anxious, pacing the room as he spoke and trying unsuccessfully to quiet the baby. He stated that the patient’s mother, who was at home in bed with mastitis, was afraid their son had become ill because she had breastfed him while she had a fever. The father confessed that he was concerned that their older son, a rambunctious 2-year-old who shares the same room as the patient, may have accidentally done something to harm the baby unbeknownst to him or his wife.

In relating the history, the infant’s father was almost tearful as he admitted that he and his wife felt completely overwhelmed and helpless that they were not able to soothe or comfort the patient.

Overview

While often the healthiest of patients seen in the ED, infants with unexplained, prolonged crying are challenging to evaluate and discharge—especially in the care of distraught parents. The following review is intended to provide a basis for understanding the scope of normal crying in infants, how and if to diagnose infantile colic in the ED, and how to avoid missing common pathology requiring acute management in the infant with new, unexplained crying.

Normal Crying: How Much Is Too Much?

During the first 3 to 4 months of life, infants cry more than at any other time. Developmental pediatrician Harvey Karp, MD, dubs the first 3 months of an infant’s life as the “fourth trimester,” during which period the baby yearns for the calming acoustic and tactile sensations of the womb. He notes that crying in this fourth trimester is merely a response to the abruptly distinct stimulation of the outside world.¹ Just as each baby tolerates these new sensations differently after birth, and is soothed in her or his own measure, each parent too has a different perception and tolerance of an infant’s crying—making for a clinical parameter that is difficult to clearly assess.

What, then has been established as the upper limit of normal for crying in infancy? In the 1960s, Brazelton’s studies defined normal crying as 1 hour and 45 minutes per day at age 2 weeks; 2 hours and 45 minutes at age 6 weeks; and less than 1 hour per day by age 12 weeks.² A more recent meta-analysis reinforces Brazelton’s criteria, indicating that the mean duration of crying is approximately 2 hours per day during the first 6 weeks of life and decreasing to a daily mean of 72 minutes by age 10 to 12 weeks.³

Infantile Colic

As the caregiver’s report of the duration of crying is often subjective, more emphasis has been placed on evaluating patterns of newborn crying by defining what is excessive. Infantile colic, or excessive crying in an otherwise healthy baby, is classically defined as fussing or crying lasting more than 3 hours per day and occurring on more than 3 days per week in a baby who is gaining weight and is otherwise well.⁴ Severe colic is further described as the persistence of the crying pattern for more than 3 weeks. When using this “rule of 3s,” excessive crying is estimated to be present in 1.5% to 11.9% of the infant population. There are, however, many other definitions of what constitutes excessive crying, including the more inclusive and subjective definition of colic as “intermittent, unexplained crying during the first 3 months of life that reaches a point where the parents complain about it.”⁵

Depending upon the definition utilized, as many as 43% of infants experience excessive crying.⁶ What is more uniformly accepted in the extensive literature on infantile colic is the observation that crying because of colic is concentrated during the hours of 3:00 pm to 11:00 pm and is associated with infant behaviors such as clenched fists, back-arching, passing gas, grimacing, and flexing legs, as well as with maternal anxiety.^1,2,7,8

Diagnostic Certainty and Setting

Infantile colic is a diagnosis that is made retrospectively in the setting of an otherwise healthy infant who is growing and developing appropriately, and whose excessive crying ultimately resolves without medical intervention. Since colic is difficult to diagnose from any single medical encounter in the ED, it must be a diagnosis reached after excluding other possible causes.

Soothing the Colicky Infant

Extensive parental reassurance is required prior to discharging a colicky infant home—with the understanding that by the time of presentation in the ED, most parents have already exhausted their parental soothing abilities and personal coping mechanisms. Moreover, the typical physician’s promise that “this too, shall pass” is just not a sufficient addition to the parental armamentarium to manage their baby’s colic. Parents instead must be given effective techniques to calm colicky infants. Karp enumerates the following alliterative “5 Ss” guideline for soothing and calming fussy infants:

(1) Swaddling;
(2) Side/Stomach position (not while sleeping);
(3)“Shhhhhing” to provide a soothing sound that recalls the womb;
(4) Swinging the baby rhythmically in parents’ arms; and
(5) Sucking, either a pacifier or the mother’s breast.¹

Equally important guidance prior to discharge from the ED is to inform parents that if they become overwhelmed by the baby’s fussing, it is always better to place an infant in the crib and let him or her cry alone for some time rather than allowing frustration to build with the baby in one's arms and increasing the potential of unintentionally harming the infant.

The “Don’t Miss” Differential Diagnoses

Whereas, as much as 43% of the infant population may experience excessive crying, only approximately 5% of infants with colic have underlying organic disease.⁸ The emergency physician (EP) is responsible for identifying this 5% when these infants present to the ED. A useful way to focus the initial evaluation of excessive crying is to determine the chronicity of the infant’s symptoms. To begin with, it is important to identify those babies who are in the ED merely because they have finally overwhelmed their parents with recurrent, intermittent bouts of prolonged crying despite being otherwise healthy and maintaining eating and sleeping patterns largely unaffected by crying. These are the infants who, after a thorough physical examination revealing none of the causes described below, should be swaddled, “shhhhhh’ed,” swung, suckled, and discharged with parental reassurance.

The EP, however, must be able to differentiate the classically colicky infant described above from the baby who has acutely developed unexplained crying and is at higher risk of serious disease or condition. In a study of afebrile infants experiencing an acute episode of excessive, prolonged crying, approximately 60% had an underlying disease process requiring management.⁹ Fortunately, many of these diagnoses can be made by an astute physical examination. In addition to evaluating infants for the most typical causes of new, prolonged crying, such as otitis media and anal fissures, the following common diagnoses should be clinically excluded in all infants presenting to the ED with acute, unexplained crying.   

Corneal Abrasion

Performing a comprehensive eye examination on an inconsolable infant is not an easy task. However, corneal abrasions and foreign bodies in the eye are notorious causes of acute, excessive crying in infants—ones that are not always accompanied by conspicuous signs such as lacrimation or conjunctival injection.¹⁰

Fluorescein staining of both corneas should be performed to evaluate for a corneal abrasion. The infant’s eyelids should also be everted to look for retained foreign bodies, especially when vertical corneal abrasions have been visualized with fluorescein staining. Administering a topical ophthalmic anesthetic prior to fluorescein staining is advisable; this can be both therapeutic and diagnostic since resolution of crying after numbing the infant’s affected eye supports the diagnosis of corneal abrasion or foreign body.

Infants with corneal abrasions can be managed with a topical antibiotic ointment and 24-hour follow-up. Of note, recent studies indicate that asymptomatic corneal abrasions are extremely common in the infant period, suggesting that physicians should be careful to consider and exclude other potential causes of acute, excessive crying before attributing the symptoms to a corneal abrasion identified on examination.¹¹

Hair Tourniquet Syndrome

Also referred to as hair thread tourniquet syndrome, the circumferential constriction of an infant’s appendage with hair, thread, or another fine material may present with the chief complaint of crying. Hair tourniquets most often involve the toes, followed by the fingers and external genitalia, and, if unrecognized or untreated, will lead to ischemia and necrosis of the distal tissue. Sleepwear that encloses the feet is a strong

risk factor for toe tourniquets, and the use of mittens is similarly linked to finger tourniquets.^7,12

The crying or irritable infant merits a thorough examination of all digits and external genitalia in search of constricting bands and resultant tissue swelling. If the tourniquet has gone unnoticed over time, severe swelling, embedding of the thread, or re-epithelialization of the skin over lacerated tissue may obscure the band and make simple removal impossible. In cases when the constricting band cannot be directly unwound, treatment options for a hair tourniquet include application of a depilatory agent (eg, Nair), which has been shown to effectively dissolve the hair within 8 minutes.¹³ If a severe laceration is present and the thread cannot be removed by unwinding, the depilatory agent should not be applied to open tissue; instead, the clinician should perform a dorsal incision of the toe or finger to remove the constricting material in its entirety.

Testicular Torsion

Testicular torsion is a common urologic emergency in the male pediatric population, with up to 12% of all cases occurring within the first year of life. It should be considered in any infant who develops acute, prolonged, unexplained crying. Eighty-five percent of infants with torsion between 1 and 12 months old will present with irritability, and 92% will present with a tender scrotal or inguinal mass¹⁴ that may go unnoticed by the parents. This possibility alone is a compelling reason to remove the diaper of an infant with prolonged crying and to perform a thorough physical examination.

While testicular deformity or a high-riding testicle can be difficult to assess on a crying baby, any scrotal enlargement, tenderness, or color change merits an emergent urology consult—and likely ultrasound imaging with Doppler sonography. Efficient and rapid management of infants with testicular torsion is essential as the testicular salvage rate is historically very poor in this population.¹⁵

Inguinal Hernia

The reported incidence of pediatric inguinal hernia is between 0.8% and 4.4%, with most patients presenting with a chief complaint of inguinal swelling. Inguinal hernias alone are symptomatic in up to 25% of infants and may present as prolonged crying.¹⁶ In these cases, inguinal hernia surgery is usually scheduled as an elective outpatient procedure. Serious issues arise when the bowel becomes edematous and incarcerated in the hernial sac, which can lead to ischemic necrosis and intestinal perforation, intestinal obstruction, and gonadal necrosis.

More than half of all cases of pediatric incarcerated hernias occur within the first 6 months of life. Infants younger than age 12 months—especially neonates—have a more severe and a higher incidence of complications related to incarcerated inguinal hernias than the rest of the pediatric population. In a recent study, one third of newborn patients were diagnosed with incarceration as their initial presentation of an inguinal hernia.¹⁷ This is another reason to remove the patient’s diaper and perform a complete physical examination on any infant presenting with acute, unexplained crying. An incarcerated inguinal hernia will likely be identified as a tender, firm, inguinal or scrotal mass with overlying swelling or discoloration and is a surgical emergency if it cannot be reduced manually.

Nonaccidental Trauma

Emergency physicians must maintain a high index of suspicion for nonaccidental trauma in pediatric patients. Studies demonstrate that 95% of serious intracranial injuries and 64% of all head injuries in infants younger than age 12 months are the result of physical abuse. Equally discouraging is the finding that as many as 75% of child abuse cases presenting to EDs are unrecognized.^18,19 Infants presenting with excessive crying have elevated risk for nonaccidental trauma both because their crying may be a result of injuries sustained from physical abuse and also because their prolonged crying itself may have been a precipitating factor in nonaccidental trauma.

Stress predisposes a caregiver to child abuse and is particularly important to identify when evaluating an infant with prolonged crying and also when providing guidance to the parents of a child with symptoms of infantile colic. Additional signs of possible nonaccidental trauma include an inconsistent history, a delay in seeking medical care, inappropriate affect of the caregiver, and an injury that is not well explained by the caregiver’s history or is incompatible with the developmental stage of the child.

Other Causes

While there are no specific laboratory tests required for the diagnosis of the abovementioned common neonatal causes of acute, prolonged crying, the EP must always consider life-threatening conditions in the inconsolable or irritable infant, including dehydration, early shock, meningitis, and a surgical abdomen. The pursuit of an appropriate workup for these diseases, accompanied by an awareness that infants may present atypically (eg, hypothermic instead of febrile) will often lead to comprehensive laboratory studies.

The EP additionally cannot undervalue the importance of trending vital signs and should never assume that tachycardia and tachypnea are due to crying alone. The onus is on the EP to consider and exclude serious illness, and nonemergent causes of prolonged crying should not be diagnosed in the setting of lethargy or poor feeding without a thorough workup. Any infant who is crying too much and eating too little per parental history is an infant who should be screened for possible underlying serious disease.

Case Conclusion

The patient in this case was found to be afebrile, tachycardic, tachypneic, and with a normal oxygen saturation while crying inconsolably on initial examination. Upon removal of the infant’s closed-footed pajamas, the distal second toe of his right foot was noted to be markedly swollen and erythematous. The EP recognized the presence of a hair tourniquet but was unable to unwind the constricting hair due to the small size of the infant’s toe and extent of tissue swelling. Topical anesthetic cream was first applied to the toe and, as there was no visible laceration of the skin, depilatory cream was subsequently applied to the tourniquet. After 10 minutes, the toe was rubbed and rinsed with water and the hair tourniquet dissolved. There was significant improvement in tissue swelling and color within 1 hour of removal of the constricting band. The affected toe demonstrated adequate capillary refill and no sign of persistent vascular compromise. The patient’s crying subsided and his vital signs and remainder of his physical examination were normal.

Since there was evidence of superficial skin breakdown at the site of the hair tourniquet, the patient’s father was instructed to apply topical antibiotic ointment to the site and to follow-up with the patient’s pediatrician in 24 hours. Of note, the father stated that the infant’s mother had been experiencing significant postpartum hair loss recently and that they would now be careful to remove loose hair from the baby’s clothing and bedding—especially when dressing him in closed-footed pajamas or mittens. 

Dr Leader is a fellow, department of pediatric emergency medicine, Eastern Virginia Medical School, Norfolk, Virginia. Dr Clingenpeel is a fellowship director, pediatric emergency medicine, and associate professor of pediatrics, Eastern Virginia Medical School, Norfolk.