Background
During the first three months of life, neonates cry more than any other time in infancy and childhood. During the first six weeks of life, infants cry an average of 117 to 133 minutes per day, and by 12 weeks, infants are crying about 60 to 80 minutes per day. (1) Crying can be very distressing to both inexperienced and experienced parents, which may bring them and their fussy infant to your outpatient clinic or the emergency department (ED).
A fussy infant also can be distressing to inexperienced and experienced providers. The infant’s evaluation should include questions about birth history, feeding history, attempts to console, and a review of systems. The mnemonic device IT CRIES can be helpful in addressing potential causes of the baby’s fussiness.(2)
Expanded Differential
Below is the list of possible diagnoses for a fussy infant when being evaluated in the outpatient or ED setting.
I – Infections
T – Trauma, including accidental and non-accidental
C – Cardiovascular disease
R – Reflux, Reaction (food or medication), Rectal fissure, rash
I – Intussusception
E – Eye (corneal abrasion)
S – Surgical (Volvulus)
ED Evaluation
Colic is a diagnosis of exclusion, and the above diagnoses should be ruled out prior to a colic diagnosis. The working diagnosis of colic uses the rule of 3’s: occurs from 3 weeks to 3 months old, 3 hours per day of crying, three days per week, for three weeks. (3) Let your physical exam and history dictate the need for laboratory and imaging studies. A few studies have suggested that all afebrile fussy infants should undergo urinalysis.(3) However, one single approach may not be indicated in all infants.(4)
Plan
After IT CRIES has been ruled out as potential causes for the fussy infant, the infant is ready for discharge. Parents will want a plan of how to console their infant. Below are some tips and tricks to communicate to new and experienced parents alike. Dr. Harvey Karp, a pediatrician, and child development expert, recommends the following: swaddle, stomach position, shush sounds, swing, suck.
Swaddle: Wrap the baby in a loose, thin blanket.
Side or Stomach Position: Hold the infant on the side or stomach may calm them down.
Shush: Mimicking a shush sound may be helpful to calm the infant.
Swing: Swinging the infant may help calm the child.
Suck: Remember a pacifier!
Conclusion
When presented with a fussy infant, our job is to rule out any diagnosis that could be life-threatening and treat emergent conditions. Colic is a diagnosis of exclusion after a more thorough list of differentials has been considered. If there are no abnormal findings, parents may need reassurance and guidance for at-home care, which may include behavioral changes and the 5 S’s.
Resources:
- Wolke D, Bilgin A, Samara M. Systematic Review and Meta-Analysis: Fussing and Crying Durations and Prevalence of Colic in Infants. J Pediatr. 2017;185:55. Epub 2017 Apr 3.
- The Fussy Infant. PEM Playbook. March 1, 2018. http://pemplaybook.org/podcast/the-fussy-infant/
- Infantile Colic. NUEM Blog, Emergency Medicine Resident Educations. September 19, 2016. http://www.nuemblog.com/blog/infantile-colic
- Fox, Sean. Inconsolable Infant. Pediatric EM Morsels. June 25, 2015. https://pedemmorsels.com/inconsolable-infant/