Approach to History and Physical Examination in an Infant with Inconsolable Crying
A thorough history and physical examination are essential for identifying the cause of inconsolable crying in infants, with particular attention to ruling out serious underlying conditions that may require urgent intervention. 1
Initial Assessment
- Determine if the crying pattern follows the "rule of three" for infantile colic: crying for more than three hours per day, for more than three days per week, and for longer than three weeks in an otherwise healthy infant 2
- Assess the infant's general appearance - an unwell appearance is strongly associated with serious underlying etiologies 3
- Evaluate vital signs, including temperature, heart rate, respiratory rate, and blood pressure 1
- Document the crying pattern: onset, duration, timing, and any potential triggers or alleviating factors 1
Key History Elements
History of the Event
- Who reported/witnessed the crying episode? Assess reliability of historian 1
- Where did it occur (home/elsewhere, crib/floor)? 1
- Was the infant awake or asleep before crying began? 1
- Position during crying (supine, prone, upright, sitting)? 1
- Was the infant feeding? Any choking, gagging, or vomiting? 1
- Were there objects nearby that could cause discomfort or injury? 1
State During Crying Episode
- Did the infant make choking or gagging noises? 1
- Was the infant active/moving or quiet/flaccid? 1
- Was the infant conscious and responsive? 1
- Was muscle tone increased or decreased? 1
- Were there any repetitive movements suggestive of seizures? 1
- Did the infant appear distressed or alarmed? 1
- Was breathing normal or labored? 1
- What was the skin color (normal, pale, red, or blue)? 1
- Was there bleeding from nose or mouth? 1
- What was the color of the lips (normal, pale, or blue)? 1
Resolution of Crying
- What was the approximate duration of crying? 1
- How did it stop (with no intervention, picking up, positioning, back rubbing)? 1
- Did it end abruptly or gradually? 1
- Was any treatment provided by parent/caregiver? 1
Recent History
- Has the infant been ill in the preceding days? 1
- If yes, document signs/symptoms (fussiness, decreased activity, fever, congestion, rhinorrhea, cough, vomiting, diarrhea, decreased intake, poor sleep) 1
- Any recent injuries, falls, or unexplained bruising? 1
- Recent immunizations or medication use? 1
Past Medical History
- Pre/perinatal history and gestational age 1
- Was newborn screening normal? 1
- Previous episodes of inconsolable crying? 1
- History of reflux, breathing problems, or snoring? 1
- Growth patterns and developmental milestones 1
- Previous illnesses, injuries, hospitalizations, or surgeries 1
Family History
- Sudden unexplained death in family members before age 35, particularly as infants 1
- Similar episodes in siblings 1
- Cardiac conditions (Long QT syndrome, arrhythmias) 1
- Metabolic disorders or genetic diseases 1
Social History
- Family structure and individuals living in the home 1
- Recent changes, stressors, or conflicts in the home environment 1
- Exposure to tobacco smoke, toxic substances, or drugs 1
- Support systems and access to resources 1
Physical Examination
General Assessment
- Evaluate overall appearance, level of alertness, and responsiveness 1
- Assess for signs of distress, pain, or discomfort 1
- Look for altered mental status, lethargy, or somnolence 1
Vital Signs
- Check temperature, heart rate, respiratory rate, and blood pressure 1
- Assess oxygen saturation if respiratory concerns are present 1
Comprehensive Head-to-Toe Examination
- Head: Check fontanelles (bulging or sunken), scalp for injuries or hematomas 1
- Eyes: Examine for tonic eye deviation, nystagmus, or other abnormalities 1
- Ears: Inspect for signs of infection or foreign bodies 1
- Nose and throat: Look for congestion, discharge, or signs of infection 1
- Chest: Assess respiratory effort, listen for wheezing, crackles, or abnormal heart sounds 1
- Abdomen: Palpate for tenderness, distension, masses, or organomegaly 1
- Genitourinary: Check for signs of infection or irritation 1
- Extremities: Examine for signs of trauma, swelling, or limited movement 1
- Skin: Look for rashes, bruising, or other lesions 1
- Neurological: Assess tone, reflexes, and symmetry of movement 1
Special Considerations
Child Abuse Evaluation
- Look for multiple or changing versions of the history 1
- Assess if history is consistent with the child's developmental stage 1
- Document any unexplained bruising 1
- Note any incongruence between caregiver expectations and child's developmental stage 1
Focused Evaluations Based on Clinical Suspicion
- For infants under 3 months with inconsolable crying and no clear cause on history and physical examination, consider urinary tract infection evaluation 3
- Consider scorpion envenomation in endemic areas, even when only presenting with inconsolable crying and tachycardia 4
- For persistent crying with neurological concerns, evaluate for seizure activity including infantile spasms 1
- For crying after feeding, consider gastroesophageal reflux or cow's milk protein intolerance 2
Diagnostic Testing
- Laboratory and imaging studies should be guided by history and physical examination findings 3
- For afebrile infants under 4 months with no clear cause, urine testing is recommended (10% positive rate in infants <1 month) 3
- Routine testing is not recommended for well-appearing infants with normal physical examinations 3
- Consider metabolic testing only if specific concerns exist from history or examination 1