What are the differential diagnoses and management options for an inconsolable cry?

Differential Diagnoses for Inconsolable Crying in Infants

Inconsolable crying in infants requires systematic evaluation starting with vital signs assessment and a comprehensive head-to-toe examination to identify potentially serious causes before attributing symptoms to benign conditions like colic. 1

Initial Assessment Framework

The evaluation must begin with documentation of:

• Vital signs including temperature, heart rate, respiratory rate, and blood pressure 1
• Crying pattern characteristics: onset, duration, timing, and any triggers or alleviating factors 1
• Reliability of the historian and circumstances: who witnessed the episode, where it occurred, and the infant's position during crying 1

Critical Differential Diagnoses by System

Ophthalmologic

• Corneal abrasion should be considered in otherwise asymptomatic infants with inconsolable crying 2
• Perform fluorescein examination if no other cause is apparent

Traumatic/Non-Accidental Injury

• Evaluate for child abuse by looking for multiple or changing versions of history, assessing if the history matches developmental stage, and documenting any unexplained bruising 1
• Consider occult fractures, particularly in pre-ambulatory infants

Gastrointestinal

• Infantile colic: paroxysms of inconsolable crying >3 hours/day, >3 days/week, for >3 weeks, affecting 10-40% of infants worldwide, peaking at 6 weeks and resolving by 3-6 months 3
• Gastroesophageal reflux: consider if accompanied by vomiting and feeding difficulties 4
• Intussusception, incarcerated hernia, testicular torsion, or hair tourniquet

Infectious/Inflammatory

• Meningitis, urinary tract infection, otitis media
• Metabolic testing should only be considered if specific concerns exist from history or examination 1

Toxicologic

• Scorpion envenomation can present with inconsolable crying and tachycardia as the only manifestations, without somatic or cranial nerve dysfunction 5
• Consider environmental exposures and bites/stings in appropriate contexts

Neurologic

• Seizure activity should be part of focused evaluation based on clinical suspicion 1
• Consider if episodes include altered consciousness or abnormal movements

Essential History Components

Perinatal and Past Medical History

• Pre/perinatal history and gestational age 1
• Previous episodes of inconsolable crying, history of reflux, breathing problems, or snoring 1
• Growth patterns and developmental milestones 1

Family History Red Flags

• Sudden unexplained death in family members before age 35 1
• Similar episodes in siblings 1
• Cardiac conditions, metabolic disorders, or genetic diseases 1

Physical Examination Priorities

Perform a systematic head-to-toe examination including:

• Overall appearance, level of alertness, and responsiveness 1
• Skin examination for bruising, petechiae, or signs of trauma
• Fontanelle assessment for bulging or depression
• Ear, nose, and throat examination
• Cardiovascular and respiratory examination
• Abdominal examination for distension, masses, or tenderness
• Extremity examination for swelling, deformity, or hair tourniquets
• Neurologic assessment

Management Approach for Benign Causes

When Colic is Diagnosed (After Exclusion of Serious Causes)

For breastfed infants:

• Lactobacillus reuteri (strain DSM 17938) is an effective treatment option 3
• Reducing maternal dietary allergen intake 3

For formula-fed infants:

• Switching to hydrolyzed formula 3

Ineffective or contraindicated treatments:

• Simethicone and proton pump inhibitors are ineffective 3
• Dicyclomine is contraindicated 3
• Evidence does not support chiropractic manipulation, osteopathic manipulation, infant massage, swaddling, acupuncture, or herbal supplements 3

Parental support and reassurance are key components of colic management 3

Common Pitfalls to Avoid

• Do not dismiss inconsolable crying as "just colic" without completing a thorough evaluation for serious causes 1
• Do not confuse persistent inconsolable crying after DTaP vaccination (which is a precaution for future doses if lasting ≥3 hours within 48 hours) with other causes requiring immediate evaluation 6
• Remember that normal infant crying during procedures is acceptable and expected; the focus should be on immobilization rather than stopping the crying 6
• Consider uncommon causes like envenomation in appropriate geographic contexts 5