Paediatric Acute care Guidelines PMH Emergency Department

Background

Crying is normal and research has shown that young infants cry for an average of 2-3 hours per day.  Crying develops in the early weeks of life and peaks around 6-8 weeks.

Parents present concerned, distressed, exhausted and confused, having often received conflicting advice from various health professionals and lay sources.

Our role in the Emergency Department is to not only identify those babies with a medical cause for crying but to also reassure, support and assist parents if the diagnosis of physiological crying is made.

 

Assessment

  • A full history and examination should be carried out including birth history, feeding (volume, frequency, type of milk), weight gain, bowel frequency
  • In young infants, ask about sleeping and awake times
  • The aim of the assessment is to exclude pathological causes for crying and identify physiological causes

History

  • Ask parents what they think the cause is and what they are concerned about.  Take their concerns seriously and complete a full examination even if the baby is no longer crying.
  • It takes a lot of effort to leave the house in the middle of the night with a small child and parents should be supported and feel their concerns are being heard
  • Crying infants are one of the most common stress factors associated with Shaken Baby Syndrome and this presentation should not be taken lightly.  Any concern regarding the cause of crying and parental ability to care should result in admission for observation and support.

Differential diagnoses

Pathological Causes

Often more acute history and associated clinical signs on examination

Sepsis

  • Babies may present febrile or hypothermic
  • Constant irritability

Intracranial Pathology

  • Consider in all persistently irritable infants

Gastrointestinal Causes

  • Cow’s Milk Intolerance
    • Consider if there is vomiting, evidence of colitis, family history of atopy, significant feeding problems worsening with time
  • Gastro-Oesophageal Reflux
    • Screaming during feed time with feed refusal after starting a feed is typical
    • Upright position during feeding, keeping upright after feeding, regular winding during feeds and feed thickeners can help
    • Proton pump inhibitors are often used but their benefit is uncertain
    • If the baby is not gaining weight or losing weight then a more detailed investigations should be performed by the General Paediatric Team
  • Intussusception
    • Acute onset
    • Pale, floppy, drawing up of legs and blood in stool is a typical presentation but not always present
    • Consider diagnosis and exclude on clinical examination
    • See Intussusception Guideline
  • Constipation
    • Delayed gut transit is normal especially in the neonatal period
    • Colostrum is a stimulant laxative so initially breast fed babies open their bowels regularly but this slows down once the milk supply is established
    • Delayed meconium (>24hrs) is a concerning feature and these babies should be discussed with the Paediatric Surgical Team
    • Excessive screaming during defecation and blood passed with the stool may indicate an anal fissure
    • See Constipation Guideline
  • Oral Candida
    • Crying with feeds and refusal to suck
    • Clinical examination of the mouth diagnoses the condition – swabs are not required unless ongoing symptoms despite treatment
  • Incarcerated Hernia
    • Typically a history of a groin lump “that comes and goes”
    • Requires immediate referral and review by the Paediatric Surgical Team
  • Testicular Torsion
    • Very rare in the neonatal period but must be considered
    • Pain on palpation, swelling and erythema

Orthopaedic Problems

  • Fractures
    • All long bones should be examined
    • Always suspect if bruising present in non mobile infants
    • Check the Moro Reflex – unilateral is suggestive of clavicle #
  • Osteomyelitis/Septic Arthritis
    • Pain on specific movement (e.g. cries with nappy change or lying flat)
  • Hair Tourniquet
    • Examine all digits and the penis carefully to exclude a hair tourniquet
    • This requires immediate referral to the Paediatric Surgical or Orthopaedic Team for removal under anaesthesia

Ophthalmology

  • Corneal Abrasion / Foreign Body
    • Common in young infants
    • Studies have shown inconclusive evidence of the relationship to crying episodes
    • All babies with consistent crying should undergo a basic eye examination including fluoroscein staining
    • By 6 weeks of age, babies should be able to fix and follow to 90º
    • Check the red reflex in all infants who present to the ED

Clinical Bottom Line…

Sudden onset of irritability and crying must not be diagnosed as colic and another cause can usually be identified.

Admission must be considered for observation, investigation and parental respite and reassurance.

Non Pathological Causes

Hunger

  • Most common cause of crying
  • Newborn babies feed every 2-4 hours
  • Cry is often loud and demanding and feeding instantaneously stops the cry
  • Poor milk supply may result in a baby that is sated but starts crying after detaching from the breast.  Ask the mother about breast engorgement pre-feeds, let down and check the baby for weight gain

Tiredness

  • Overtired babies cry and are irritable, fighting off sleep they desperately need
  • Average sleep requirements for a 24 hour period:
    • Newborn:  16 hours – awake time max 1.5 hours
    • 3 Months:  15 hours – awake time max 2 hours

Discomfort

  • Babies cry when their nappies are wet or soiled but also if they are too hot or too cold
  • Ask about sleeping arrangements

Wind

  • Crying post feeds or waking shortly after being put into the cot at night are often due to wind
  • Advise the parents to wind frequently during the feed and ensure bottle teats are full of milk to avoid increased air swallowing

Colic

  • Excessive crying (>3 hours /day) in an otherwise healthy infant is often termed colic
  • It is recurrent, typically in the afternoon and evening and usually resolves by 4 months of age

Management

Referrals and follow-up

Advice and Follow-up for Non Pathological Causes

  • Listen to the parents concern and give them your time
  • Explain normal sleep and crying patterns
    • Advise use of diary to see the pattern of crying
    • Work out how much sleep is need and duration of awake time
    • Encourage parents to recognise the signs of tiredness
    • Discuss ways to comfort the crying baby
    • Allow the mother to discuss the stress related to having a baby that cries constantly – consider screening for postnatal depression
  • Follow-up with the child health nurse within the week
  • Inform the GP by letter of attendance and the information you have given the parents

Health information (for carers)

For Further Information:

Ngala
WA based charity with information on-line, advisors contactable by phone and they offer day and overnight stays to observe sleeping and crying patterns

Pregnancy, Birth and Baby
Government site offering 24 hour advice helpline and on-line resources

Raising Children Network 
Australian parenting website

Child Health Clinics
Access Child Health Nurses in your area

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