IT CRIES…But Now You Won’t—Approach to the Fussy Infant
Dr. Elizabeth Lehto
Case
A two-month-old infant presents to the emergency department with the chief complaint of fussiness for the past two hours. On examination the infant is fussy, but you aren’t able to determine an obvious source of the fussiness. You are unsure of what to do next, but then remember a helpful mnemonic for the differential of a fussy infant: IT CRIES.
I—Infection
Often infection presents with fever, however fussiness may be the only sign. Meningitis and sepsis are the most worrisome infections. Patients may have fever, decreased energy levels, not waking for feeds, or building fontanelle. Infants with meningitis may have paradoxical irritability, which is worsening fussiness when the infant is held by the parents.
Other infections to keep in mind are urinary tract infections. These also typically have fever but can present with fussiness alone.1 Candida infection, including thrush (presents as white plaques on the tongue or buccal mucosa) and diaper candidiasis (erythematous plaques with surrounding satellite lesions, located in the skin folds). Perirectal streptococcus, seen as a beefy red rash in the perirectal area.²
T—Trauma
Trauma in infants, including subdural hematoma, fractures, and non-accidental trauma, can present as isolated fussiness. Family may give a history of a patient falling or being dropped. Have a high suspicion for non-accidental trauma if a family gives a history of a patient less than 4-6 months rolling off a couch or bed, as babies typically roll from front to back around 4 months and roll in both directions around 6 months.
On physical examination look carefully for pain on movement of extremities or with palpation of extremities.² Also, be sure to do a thorough skin examination for bruising. Remember, those who don’t cruise rarely bruise.
C—Cardiac
Infants with cardiac issues including myocarditis, congestive heart failure, or supraventricular tachycardia may present with fussiness. Infants with myocarditis or congestive heart failure may present with fussiness or increased sleepiness. They are often tachypneic and have difficulty feeding. Hands and they may have decreased urine output. Exam may reveal a murmur or hepatomegaly.²
Infants with supraventricular tachycardia typically have a history of fussiness or not eating. Heart rate is consistently above 220, and echocardiogram shows p-waves hidden in the QRS complex.²
R—Reaction to Medications, Reflux, Rectal/Anal Fissure
Medication reactions can lead to infant fussiness. These can be medications the patient is taking or, if breast feeding, medications mother is taking. A thorough history of timing of medications and pattern of fussiness can help determine if this is the cause.
Reflux is common in infants. Small volumes of spitting up, even if frequent, can be normal. If spitting up is painful or the infant has lost weight, there is concern for gastroesophageal reflux disease and patient may benefit from medication.
Rectal fissures can be from forceful Valsalva maneuvers as seen in constipation. Fissures from constipation usually occur at the 12 o’clock or 6 o’clock position (benign occurs at midline). When fissures are off midline, typically in the 4 o’clock or 8 o’clock position, think of a tear because something is being inserted. This may be innocent like too many enemas in a constipated child or frequent temperature checks, but can also be a sign of abuse.
I—Intussusception
Intussusception typically presents with the classic triad of colicky abdominal pain (however patient may be lethargic), a sausage shaped abdominal mass, and currant jelly stools. Note that currant jelly stools are a late finding. Peak incidence for intussusception is between 6 and 9 months, but it can present sooner.²
E—Eyes
Corneal abrasion or foreign body can present as isolated fussiness. They are diagnosed with a fluoresceine examination. When doing this examination be sure to evert the eyelid to look for a foreign body.²
Glaucoma should be suspected in a patient presenting with fussiness, excessive tearing, photophobia, blepharospasm (eyelid twitching), corneal clouding, or conjunctival injection.²
S—Strangulation, Surgical Process
When examining an infant, it is important to do a thorough examination of the fingers, toes, and genitals to evaluate for strangulation of a digit or penis by a hair tourniquet. This presents as a painful swollen digit or penis, typically at the distal end.
Fussiness may also be caused by a hernia or torsion of the testes or ovaries. Evaluate for presence of scrotal swelling. Ovarian torsion is harder to diagnose on physical examination and is worth ruling out in a persistently fussy female that has no other source of fussiness.²
Back to Our Patient
Using the IT CRIES mnemonic, you go back in the room to double check that you’ve done a thorough history and physical examination.
I—Infection: Patient has been afebrile without building fontanelle or paradoxical fussiness and does not have a rash. Based on this you have a lower suspicion for infection but do consider a urinalysis to rule out urinary tract infection if you can’t find the source of fussiness.
T—Trauma: Family denies history of patient rolling or falling. There is no bruising and no tenderness to palpation over the extremities. You have a lower suspicion for trauma at this point, but if the diagnosis continues to remain elusive consider getting a head CT to rule out a subdural hematoma.
C—Cardiac: The patient does have an elevated heart rate, but not quite 220 and it is variable, so supraventricular tachycardia is unlikely. There is no history of trouble feeding or cyanosis, so cardiac issues are unlikely at this time.
R—Reaction to meds, reflux, rectal fissure: Neither mother or patient are taking any medications, so medication reaction is unlikely. The patient does have small volumes of spitting up with feeds, but it doesn’t seem to be causing the patient any pain and weight gain has been good, so reflux is less likely to be the source of fussiness. There is no history of constipation and no rectal fissures on examination.
I—Intussusception: Fussiness has been constant as opposed to colicky. There is no sausage shaped mass or currant jelly stools. At two months old, intussusception is less likely, but you consider getting an abdominal ultrasound if the source of fussiness remains elusive.
E—Eyes: Patient does not have a history of tearing, blepharospasm, corneal clouding, or other symptoms suggestive of glaucoma. Fluoresceine examination is completed and does not show a corneal abrasion.
S—Strangulation, Surgical Process: Patient does not have pain or swelling of the scrotum, which makes hernia or torsion less likely. While doing your head-to-toe examination you realize that the first time around you didn’t remove the patient’s socks. On closer examination you realize that the right fifth digit is erythematous and swollen, and you can see a hair wrapped around the base of the digit.
You apply a depilatory cream to the hair and remove it, with return of the digit to its normal color and resolution of fussiness. The patient’s mother is grateful that you were able to help her baby and you are thankful that you were able to use your history and physical examination to find the source of the fussiness.
What About Colic?
Fussiness may be due to colic, but keep in mind it is a diagnosis of exclusion. Colic is diagnosed in a patient that has excessive crying for more than 3 hours per day, more than three days per week, and for more than 3 weeks in duration. It can begin as early as the second week of life and peaks around the sixth week of life. Colic typically starts to decline at around 3 months of age.²,³
Bottom Line
A thorough history and physical examination is the best tool to help determine the cause of crying in a fussy infant. After a thorough examination, if the source of fussiness remains unclear you may consider obtaining a urinalysis to rule out urinary tract infection, head CT to rule out subdural hematoma, or abdominal ultrasound to rule out intussusception. While it may be tempting to attribute crying to colic, keep in mind that this is a diagnosis of exclusion, so other sources need to be ruled out first.
Elizabeth Lehto, D.O.
University of Louisville | UL · Department of Pediatrics | Doctor of Pediatric Emergency Medicine
Dr. Elizabeth Lehto is a Pediatric Emergency Medicine Attending at Norton Womens and Children’s Hospital. Dr. Lehto attended Midwestern University Arizona College of Osteopathic Medicine and completed her residency and fellowship at the University of Louisville.
References:
Freedman SB, Al-Harthy N, Thull-Freedman J. The crying infant: diagnostic testing and frequency of serious underlying disease. Pediatrics. 2009;123(3):841-848.
Herman M, Le A. The crying infant. Emerg Med Clin North Am. 2007;25(4):1137-1159, vii.
Cohen GM, Albertini LW. Colic. Pediatr Rev. 2012;33(7):332-333; discussion 333.
