• Contact
  • ☎
  • ✉
  • LinkedIn
  • Facebook
  • X

Society for Pediatric Urgent Care

Warning: Your Internet Explorer TLS settings may not be updated with the latest security settings. To fix this issue and resolve any connection errors,
×

Updating IE TLS Security Settings:

• Open Internet Explorer
• Go to the Tools menu on your computer (the icon shaped like a gear—just below the “X” to exit the program)
• Select Internet Options from the drop down menu
• Select the Advanced tab
• Find the item on the advanced menu that says Security
• There should be three items called “TLS” (1.0, 1.1, 1.2). Make sure the box next to these three items is checked and click Apply
• Close your browser and reopen Internet Explorer to refresh changes

Society for Pediatric Urgent Care

We are currently experiencing a Verizon outage that is impacting our servers and telephones. As a result, some of the website is not functioning. Verizon says that the problem will be resolved within 48 hours. We apologize for the inconvenience and will remove this notice when service is restored.
  • About SPUC
    • Board of Directors
    • Committees
      • zoo-info.nl
    • History
    • Mission Statement
  • News/Resources
    • Newsletters
    • 2025 QI PROJECT: Abdominal X-Rays MOC Part 4 Credit
    • Reading Corner
    • Job Postings
    • Clinical Pathways
    • Clinical Advisor
    • Additional Resources
  • Education
    • Pediatric Urgent Care Webinars
  • JOIN
    • Group Members
    • Join
    • Membership Benefits
  • Members
    • Member Login
    • Group Members
    • Pay Dues
    • SPUC Spotlight
    • New Member Welcome Message
  • Meetings
    • Current Meeting
    • Past Meetings
    • Exhibits and Promotions Information
    • Mike Moran Scholar Award
  • Fellowships/Training
    • Pediatric Urgent Care Physician & APP Fellowship Programs
      • 1win0.co
    • Resident Elective Goals and Objectives
    • Core Competencies
  • Providers
    • Providers
    • Scope of Practice and Transfer Policies

Crying (Excessive Crying in Infants)

ALERTS

FINDINGS NOT TO MISS

 Sepsis
 Meningitis
 Intussusception

IMMEDIATE CONSIDERATIONS

 Concern for the above should prompt immediate transfer
 Consider antibiotics

AGE CONSIDERATIONS

 Infants under < 3 months at highest risk for sepsis/meningitis  Intussusception 3mo-3 years

DIFFERENTIAL DIAGNOSIS

 Broad and ranges from serious to benign

BENIGN

Anal Fissure
Colic
Corneal abrasion
Feeding Difficulties
Gas
Hair tourniquet
Hernia (unincarcerated)
Milk protein allergy
Nasal congestion
Otitis Media
Oral thrush (severe)
Gastroesophageal reflux

SERIOUS/LIFE-THREATENING

Abusive head trauma(AHT)/child abuse
Congestive heart failure
Congenital heart disease
Supraventricular tachycardia (SVT)
Drugs or drug withdrawal
Incarcerated hernia
Infection
 Sepsis
 Meningitis
 Respiratory distress
 Urinary tract infection
 Injury
 Intussusception
 Metabolic disturbances
 Testicular/ovarian torsion

EVALUATION

HISTORY

 Full history, including social history
 Is crying intermittent or persistent?

PHYSICAL EXAM

 Complete physical exam is essential
 Remove all clothing, including diaper
 Infants who are lethargic or remain persistently irritable during your exam are more likely to have a serious cause for their crying

Vital signs

Fever, tachycardia or tachypnea

  • markers of infection/sepsis, cardiovascular or respiratory disease or metabolic derangements.
  • Normal ranges vary by infant age, understand what is considered out of range.

General: lethargic or asleep, but arousable? Crying or generally fussy?
Skin:

  • Remove the diaper and all of the clothing
  • Careful skin exam for any swelling or evidence of cellulitis/abscess
  • Skin mottling and acrocyanosis can be normal in newborns, but in the presence of other physical exam findings, such as fever or lethargy, they may be markers of shock.
  • Petechiae and purpura are late findings in sepsis.

HEENT:

 Head:

  •  Fontanel: fullness/bulging (concern for meningitis – late sign )
  •  Skull: swelling or bogginess (concern for skull fracture).

 Ears: otits media
 Eyes : Corneal abrasion/Foreign Body
 Mouth: thrush or oral lesions – use a tongue depressor

Cardiovascular: Congenital heart disease

  • Assess perfusion, peripheral pulses, heart rate, and presence of a heart murmur
  • Poor feeding, tachypnea/sweating during feedings may indicate congenital or acquired heart disease

Respiratory:

  • tachypnea, wheezing or grunting may indicate respiratory or cardiovascular diseases.

GastrointestinaI: intrabdominal process, intussuception,

  • Palpate: abdominal masses, abdominal distension, abdominal tenderness, and tenseness.
  • Perform a guaiac stool test for occult blood

Genitourinary:

  • Hernias or testicular torsion: Remove the diaper
  • Perirectal abscess or anal fissure: Lay in supine position, flex the hips to visualize anus

Musculoskeletal: musculoskeletal trauma, hair tourniquet
Palpate all long bones and clavicles
Check for swelling, bruising or erythema
Does crying increase when you move an extremity
Will child bear weight?
Look at all fingers and toes to be sure there are no tourniquets.

Neurologic:
Is the child consolable at all?
Paradoxical irritability (crying is made worse when holding to try to console) can be seen with meningitis.

DIAGNOSTIC TESTS & INTERPRETATION

 Guided by history and physical
 Majority of diagnoses can be made without further testing
 Colic is a diagnosis of exclusion

Lab Tests

 CBC, blood and urine culture, lumbar puncture if concern for infectious etiology

Lab Tests

 KUB for abdominal concerns including distension
 Xray for musculoskeletal concerns

MANAGEMENT

TRANSFER/ADMISSION CONSIDERATIONS

 Immediate transfer for sepsis/meningitis
 If not immediate cause and infant remain irritable, consider transfer for observation of infants < 3 months, but certainly less than 28 days  Surgical emergencies: Incarcerated hernia, intussusception, testicular torsion  Fractures requiring transfer  Concern for non-accidental trauma


Anal Fissure – see …
Colic
Corneal abrasion – see …
Feeding Difficulties – see…
Gas – see…
Gastroesophageal reflux – see…
Hair tourniquet – see…
Hernia (unincarcerated) – see…
Milk protein allergy
Nasal congestion – see…
Otitis Media – see…
Oral thrush (severe) – see…
Musculoskeletal injuries – see…

 

COLIC

  • 2-3 hours of excessive crying
  • Begins at 6 weeks, lasts to 4 months
  • Diagnosis of exclusion

TREATMENT

First Line

 Supportive care

Complementary & Alternative Therapies

 swaddling, white noise, car rides used with variable success
 Gas relief drop or gripe water, often of little benefit

PROGNOSIS, COMPLICATIONS

 Self resolves

 

PROTEIN INDUCED ENTEROCOLITIS

TREATMENT

First Line

 Elimination of cows milk and/or soy protein: elimination from nursing mother’s diet as well

Second Line

 Amino acid based formula

Supportive

 May take up to 1 week for improvement in symptoms and resolution of heme in stool
 May have associated esophagitis consider reflux treatment may improve symptoms

Complementary & Alternative Therapies

 Gas relief drop or gripe water, often of little benefit

DIAGNOSIS 3

TREATMENT

First Line

Second Line

Supportive

Complementary & Alternative Therapies

Surgery / Other Procedures

FOLLOW UP

Outpatient Referral

 Discuss with PCP if available, excessive crying is a high stress situation for families
 PCP follow up the following day for well appearing infants

Written instructions should include:

Anticipatory Guidance

 Include social support about crying
 Include information about precenting shaken baby

Activity, Diet

 As tolerated based on diagnosis

Signs and Symptoms to return

 Fever, worsening symptoms

PROGNOSIS, COMPLICATIONS

 Diagnosis dependent

REFERENCES

ADDITIONAL RESOURCES

SEE ALSO (TOPIC, ALGORITHM, ELECTRONIC MEDIA ELEMENT)

CODES

ICD9

PUBLISHER WILL ENTER

Snomed

PUBLISHER WILL ENTER

CME/REVIEW QUESTIONS

  1.  
  2.  
  3.  

Copyright © 2025 ·Metro Pro Theme · Genesis Framework by StudioPress · WordPress · Log in