What is the initial workup for a 20-month-old presenting to the emergency department (ED) with crying?

Initial Workup for a 20-Month-Old Presenting to the Emergency Department with Crying

The initial workup for a 20-month-old presenting to the emergency department with crying should focus on a thorough physical examination to identify potential serious causes, as approximately 61% of cases of acute, unexplained excessive crying in infants may have serious underlying etiologies. 1

Initial Assessment

• First verify scene safety and check for responsiveness of the child 2
• Assess airway, breathing, and circulation, checking pulse and breathing simultaneously 2
• If the child is responsive, breathing normally, and has a normal pulse, continue with detailed assessment 2
• Monitor vital signs including heart rate, respiratory rate, temperature, and oxygen saturation 2

History Taking

• Obtain detailed history about the onset, duration, and pattern of crying 1, 3
• Ask about associated symptoms such as fever, vomiting, diarrhea, or recent illness 1
• Inquire about feeding patterns, sleep patterns, and any recent changes 3
• Document any recent trauma, falls, or injuries 1
• Ask about medication use and potential exposures to toxins 1
• Review past medical history and family history 1

Physical Examination

• Conduct a comprehensive physical examination, which should include:
  • Careful skin inspection underneath all clothing (looking for rashes, bruises, or signs of trauma) 1, 4
  • Palpation of all large bones to detect fractures 1, 4
  • Fluorescein staining of the cornea to identify corneal abrasions 1, 4
  • Eversion of eyelids to check for foreign bodies 1, 4
  • Rectal examination to check for fissures or blood 1, 4
  • Retinal examination to rule out retinal hemorrhages 1, 4
  • Thorough neurological examination 1, 4
  • Examination of ears, throat, and abdomen 1, 4
  • Assessment for signs of increased intracranial pressure 1
  • Check for facial petechiae, which are rare with crying alone and may indicate trauma 5

Laboratory and Diagnostic Testing

• Urinalysis and urine culture are recommended, especially for infants under 4 months of age, as urinary tract infections are among the most common serious causes of crying 1, 4
• Other laboratory tests should be guided by history and physical examination findings rather than performed as routine screening 1, 4
• Consider additional testing based on specific concerns:
  • Complete blood count if infection is suspected 4
  • Electrolytes if dehydration is a concern 4
  • Radiographs if trauma or fracture is suspected 1

Special Considerations

• Be aware that the persistence of excessive crying after the initial examination may predict a serious cause 1
• Infants who cease crying before or during the initial assessment are less likely to have a serious cause 1
• Consider non-obvious causes such as hair tourniquet, corneal abrasion, or even scorpion envenomation in endemic areas 1, 6
• For infants with inconsolable crying and no obvious cause after initial evaluation, consider observation in the ED before discharge 4

Management Approach

• If a specific cause is identified, treat accordingly 1, 4
• If no cause is found but the child appears well, consider:
  • Discharge with close follow-up 4
  • Clear return precautions for worsening symptoms 4
  • Parent education about normal crying patterns and soothing techniques 3
• If the child appears unwell or crying persists despite intervention, consider admission for observation and further evaluation 1, 4

Pitfalls and Caveats

• Avoid attributing excessive crying solely to colic without a thorough evaluation, as serious conditions may be missed 1, 4
• Remember that history and physical examination are the cornerstones of evaluation and should drive investigation selection 4
• Be aware that some serious diagnoses may only be made on revisit, so follow-up is crucial 4
• Consider child abuse in cases with unexplained injuries, including facial petechiae 5