Excessive Crying in Children
EXCESSIVE CRYING IN CHILDREN
Crying is a response by which infants indicate their displeasure to unpleasant stimulus. Persistent inconsolable crying is referred to as excessive crying. The inability of the parents in localising the cause of crying poses a major problem.
CAUSES OF EXCESSIVE CRYING -
In infants -
Crying without disease -Strangulated hernia, torsion of testis
Discomfort - wind, cold, heat,itching, evening colic, wet napkin, loud noises, teething
Intestinal obstruction & intussusception
Cow's milk allergy
In older children -
Irritability on the breast
Personality, insecurity, habit
Crying on passing urine
Loneliness - desire to see
surroundings, or to be picked up
Crying with disease
INFANT CRYING -
1.Hunger -Most common cause
Baby feeding should be 'demand based' and not 'time based'.
Thirst due to hypernatraemia due to 'strong' feeds or over clothing or excessive sweating
Excessive cold/heat, pruritus (eczema), wet napkin, sudden loud noise
Evening colic- (`Three month colic') affect well thriving babies/bottle fed babies. Around 18:00 hours with characteristic circadian rhythm.
3.Allergy to cow's milk
Excessive crying in infant >6 months in evening
Eruption of tooth through periosteum can lead to pain. But most of crying is related to habit formation in connection with sleep due to parental mismanagement. Baby cries as it knows to get sure attention by doing so.
5.Irritability & screaming in newborn when put to breast -
Baby's nose may be obstructed by his upper lip while feeding or being blocked by mother's breast tissue. May be caused by 'forced' feeding attempted by mothers or due to withdrawal of the baby by the mother when it starts sucking (for the fear that the baby may bite her). Proper education regarding breast feeding will settle the issue.
Baby may sense mother's anxiety & tenseness & cry. Amount of crying represents interaction between his personality & that of parents.
7.While passing urine -
Normal feature up to 6 months
8.Loneliness - Baby cries when left alone & stops when lifted. Baby >6 wks may not be content to be left lying down with nothing to see.
Effort to force the child to take food May also be due to food allergy
If the crying still continues when infant is picked up & fed (might be due to abdominal pain/headache). Crying may occur when child feels tired.
Otitis media Pyelonephritis
12.Intestinal obstruction, torsion of testis, intussusception TYPES OF ABNORMAL CRY -
Bleating lamb cry - Cornelia deLange Syndrome
Cat like cry - `Cri-du-chat' syndrome
Grunting cry - Pneumonia
High pitched/ Shrill - Cerebral irritability, meningitis, hydrocephalus, & kernicterus
Hoarse cry - Laryngitis
Hoarse gruff cry - Hypothyroidism
Weak cry - Werdnig -Hoffman disease, Myasthenia gravis
Whimper cry - Seriously ill child
Infantile colic is common in first 3 months.
Intussusception occurs during weaning - 4-6 months
Trauma and falls occur after the child starts rolling/crawling - 5-8 months.
Bronchiolitis is common after 6-8 months age.
Teething - 9-12 months
Pattern & duration -
Outbursts of cry - spasmodic pain e.g. colics/sickle cell crisis
Persistent crying - Traumatic / infectious origin / anal fissure
Associated with micturition - Phimosis/UTI Types of cry - Already discussed
Associated symptoms -
Fever - Suggests infection
Respiratory symptoms - Bronchiolitis, foreign body aspiration
GI symptoms - Constipation with hard stools (Anal fissures)
Vomiting - Intracranial pathology / surgical cause.
Blood & mucus in stools- Dysentery.
CNS symptoms - Drowsiness & altered sensorium - Intracranial pathology
Urinary symptoms - Retention of urine / UT! / phimosis
Ear discharge - Otitis media
Watering & redness of eyes - Corneal foreign body
Trauma - Fractures due to vigorous massage or mal-handling or child abuse
Drugs - Nalidixic acid / vit A (Pseudotumour cerebri) ,Anticholinergic drugs (painful urinary retention)
Pruritus - Eczema/insect bite
DPI Vaccination - Can lead to irritability.
Aggravating factors - e.g. In scurry / trauma handling causes crying.
Relieving factors - e.g. Nasal block & infantile colic relieved on holding child upright.
CLINICAL EXAMINATION -
General examination -
Bleeding gums & bone
Restricted painful movements
Otitis / corneal abrasion
Tenderness - Scurvy
Bronchiolitis / FB
Fractures, arthritis, osteomyelitis Eczema / insect bite
Constipation (Anal fissure)
Retention of urine
Strangulated hernia/testicular torsion.
Systemic examination -
Abdominal examination -
Tenderness/guarding/rigidity Lump in right hypochondrium Faecal masses
Respiratory system -
Change in sensorium
Focal neurological deficits
CBC - Leucocytosis/neutrophilia - Infection (ENT / URTI / Meningitis)
Stool routine & urine routine - to rule out infection
X-ray abdomen standing view - Intestinal obstruction (air fluid levels)
X-ray of bones - Fractures/ Scurvy
Lumbar puncture / CT scan - if CNS signs predominate (Meningitis, bleed, raised intracranial tension.