An irritable infant is a challenge to the caregiver and medical provider and is a common presenting complaint in early infancy. An irritable infant is defined here as a patient younger than 1 year of age who according to the caregiver, cries excessively or is excessively fussy. There are many causes, but most irritable infants do not have significant underlying pathologic processes. However, there are serious entities that must not be missed ( Table 26.1 ).
| Emergent/Urgent Diagnoses | Nonemergent/Urgent Diagnoses |
|---|---|
| Eyes, Ears, Nose, Throat | |
| Choanal atresia | Otitis externa |
| Corneal abrasion | Teething |
| Foreign body | |
| Glaucoma | |
| Otitis media | |
| Respiratory | |
| Airway obstruction (croup, foreign body) | Upper respiratory tract infection |
| Lower respiratory tract infection (pneumonia, bronchiolitis) | |
| Cardiovascular | |
| Congestive heart failure | |
| Supraventricular tachycardia | |
| Anomalous coronary artery | |
| Myocarditis | |
| Kawasaki disease | |
| Gastrointestinal System | |
| Incarcerated hernia | Constipation |
| Gastrointestinal obstruction (intussusception, volvulus, pyloric stenosis, Hirschsprung disease) | Uncomplicated gastroenteritis Anal fissure |
| Abdominal trauma | Gastroesophageal reflux |
| Peritonitis | Inappropriate feeding volume or technique |
| Milk or soy protein allergy | |
| Genitourinary System | |
| Testicular torsion | |
| Ovarian torsion | |
| Urinary tract infection | |
| Musculoskeletal System | |
| Osteomyelitis | Minor, soft tissue injury |
| Septic arthritis | Discitis |
| Fractures | |
| Skin | |
| Cellulitis | Impetigo |
| Tourniquet syndrome (digit, genitalia) | Dermatitis |
| Insect bites | |
| Minor injury | |
| Central Nervous System | |
| Encephalitis | |
| Meningitis | |
| Increased intracranial pressure (trauma, hydrocephalus, intracranial hemorrhage) | |
| Intracranial mass | |
| Miscellaneous | |
| Drug ingestion | Vaccine reaction |
| Neonatal abstinence syndrome | Poor caregiver-infant interaction |
| Inborn error of metabolism | Normal crying |
| Sepsis | |
| Sickle cell crisis | |
| Physical abuse | |
Medical providers should also recognize the profound anxiety and stress that infant crying may place on families and other caregivers. Although excessive crying generally resolves with time, the family’s beliefs about the cause of the crying can have a lasting effect on the way they interact with the child and their beliefs about the infant’s health. Caregivers who perceived their infant’s crying as excessive or inconsolable described higher rates of depression, strained family relationships, and guilt about their inability to calm the infant. Excessive crying may even trigger thoughts of harming the infant and is reported as a common trigger for child physical abuse. Additionally, infants with early cry-fuss problems in combination with family dysfunction are at higher risk for ongoing behavioral problems, highlighting the need for early identification and intervention in this population. Therefore, the provider’s response when evaluating an irritable infant should be focused on diagnosing potentially treatable medical conditions and on addressing the caregiver’s understanding and response to the crying.
Diagnostic Approach
Less than 5-10% of infants who present for medical care due to excessive crying will have a serious underlying etiology. However, a thorough medical evaluation is needed to identify the minority of infants with treatable issues, and in healthy infants a thorough evaluation may reassure caregivers.
The initial evaluation of an irritable infant starts with a careful history and physical examination with the intent of ruling out potentially emergent conditions and stabilizing the patient if indicated ( Fig. 26.1 ). The physical examination should include a complete examination of all body systems with the clothing removed. Table 26.2 lists elements of the history and physical examination suggestive of emergent and common diagnoses that may present with a chief complaint of crying. The history should be comprehensive, given the wide array of possible diagnoses to consider. The history should include questions about the characteristics of the cry (the time of day, duration, whether it is associated with feeds) and any changes to the infant’s typical crying pattern. Infants with a sudden increase in the frequency and duration of inconsolable crying compared to normal are more likely to have an underlying medical condition. Clinicians should also ask caregivers why they think the infant is crying in order to specifically address any fears about the infant’s health.
| Review of Systems | Possible Physical Exam Findings | Diagnoses to Consider |
|---|---|---|
| Eyes, Ears, Nose, Throat | ||
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| Respiratory | ||
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| Cardiovascular | ||
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| Gastrointestinal System | ||
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| Genitourinary System | ||
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| Musculoskeletal System | ||
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| Central Nervous System | ||
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| Miscellaneous | ||
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