You hear a piercing shriek reverberate across your emergency department. The tracking board shows a chief complaint of “crying.”
What Is Normal?
Medical professionals and laypeople understand that infants cry as a primary means of communication. However, the first challenge when assessing a crying infant is determining what crying is defined as normal. The definition of normal crying originates from a 1962 article by T. Berry Brazelton, who determined that the median hours an infant spends crying is 1.75 hours a day at two weeks of age, peaks at 2.75 hours a day at six weeks of age, and decreases to less than one hour of crying a day by 12 weeks.1 As a medical provider, it is important to seriously consider the concerns of any caregiver who has noticed an acute change in the crying patterns of a child.
The physician should determine the onset, duration, frequency, and aggravating and alleviating factors of the crying and any of its associated factors. Distinctive aspects of the infant’s past medical history should be recorded, including birth history and the maternal history of prescription drug use, illicit drug use, alcohol use, and smoking. The infant’s stool frequency and consistency should be determined. Caregivers should also be screened for their response to the crying, their social support, and fatigue.2 Such factors may be associated with abuse.
A full set of vital signs should be obtained, including weight, for the evaluation of appropriate growth. Time should be taken to perform a comprehensive head-to-toe examination. The exam should include the palpation of the fontanelles and skull for fullness and hematomas. The mental status of the infant should be assessed by determining whether the infant is alert; hypoglycemia should be considered early with a depressed mental status.
The provider should consider conducting an ocular exam, including fluorescein stain and eyelid eversion to look for foreign bodies, as well as an ear exam to look for acute otitis media and foreign bodies. A tongue depressor should be used to study the infant’s oropharynx for ulcers or lacerations. Long bones and joints, including clavicles and ribs, should be examined. The chest cavity should be assessed for abnormal cardiac or lung sounds. An abdominal exam should include inspection, auscultation, and palpation. The skin should be thoroughly investigated for signs of injury, rash, or a hair tourniquet. The testicles should be evaluated for hernias, anal fissures, and signs of trauma.3 The “IT CRIES” mnemonic (see Table 1) can be helpful in conducting the initial differential diagnosis of a crying child.