What is the likely cause and recommended management for a 13‑month‑old girl with excessive crying and self‑directed facial rubbing/hitting?

Evaluation and Management of a 13-Month-Old with Excessive Crying and Self-Directed Facial Hitting

This 13-month-old is beyond the typical peak crying age (2-4 months), making organic causes, developmental issues, or behavioral dysregulation more likely than normal infant colic, and requires systematic evaluation starting with exclusion of serious medical conditions followed by assessment for self-injurious behavior patterns. 1

Immediate Medical Evaluation Required

Rule Out Serious Organic Causes First

• Check serum glucose, calcium, and magnesium immediately – hypoglycemia, hypocalcemia, and hypomagnesemia commonly cause excessive crying and jitteriness requiring urgent reversal 1
• Examine for fractures or trauma, particularly given that facial hitting could indicate pain from injury (accidental or non-accidental) 1, 2
• Look for concerning features mandating workup: bilious vomiting, gastrointestinal bleeding, fever, lethargy, hepatosplenomegaly, abdominal tenderness or distension 1, 2
• Obtain comprehensive maternal drug history, as neonatal withdrawal can present with irritability and tremors (opioids cause withdrawal in 55-94% of exposed neonates; SSRIs and benzodiazepines cause tremors and jitteriness) 1
• Consider urinary tract infection – in crying infants <1 year, UTIs are among the most common serious diagnoses, with a 10% positive culture rate in infants <1 month 3

Physical Examination Focus

• Assess for unwell appearance, which is associated with serious underlying etiologies 3
• History and physical examination identify the etiology in 66.3% of cases and should drive investigation selection 3
• Only 1.4% of diagnoses are made by investigations without suggestive clinical findings 3

Developmental and Behavioral Context

Age-Specific Considerations

• At 13 months, this child is well past the normal crying peak (2-4 months), so this presentation is atypical for standard infant colic 1, 2
• The self-directed facial hitting raises concern for either pain localization (ear infection, dental pain, sinus pressure) or emerging self-injurious behavior 1
• Excessive crying at this age may represent a behavioral and emotional regulation disorder that can manifest as chronic fussiness, excessive clinginess, or temper tantrums 4

Consider Food Allergy

• Although less common at 13 months if not previously identified, cow's milk protein intolerance can cause irritability 2
• A minority of irritable infants have food allergy as the underlying cause 5
• Trial of extensively hydrolyzed formula (if formula-fed) or maternal dietary elimination (if breastfed) may be considered if other causes excluded 2

Management Approach After Excluding Organic Causes

Parental Support and Safety Counseling

• Critical safety discussion required: Crying is the most common trigger of abusive head trauma, and approximately 6% of parents of 6-month-old infants admit to smothering, slapping, or shaking their infant at least once because of crying 1, 6
• Counsel parents explicitly that it is safe to put the baby down in a safe place and take a break if overwhelmed 1, 2
• Implement the Period of PURPLE Crying education program to improve parental knowledge about crying and behavioral responses 1, 6

Behavioral Interventions

• Parents should remain calm and serve as an "emotional container" for the child's strong emotions without becoming overwhelmed 2, 6
• Use distraction techniques such as games, music, or deep breathing to help the child regulate emotions 2
• Establish protective routines using visual and verbal cues for mealtimes and sleep times to restore order 2, 6
• Implement "time-in" or special time (10-30 minutes of child-directed play) to strengthen parent-child connection 2, 6

Environmental Modifications

• Avoid overstimulation from excessive tactile, visual, auditory, and kinesthetic stimuli 1, 2
• Gentle motion, rhythmic movement, and white noise can calm the overstimulated infant 1, 2

What NOT to Do

• Never prescribe proton pump inhibitors – they are ineffective for crying and carry risks including pneumonia and gastroenteritis 1, 2
• Do not perform extensive laboratory testing without clinical indication – only 1.4% of diagnoses come from investigations without suggestive history or examination 3
• Avoid harsh disciplinary strategies, as they promote aggressive behaviors and damage the parent-child relationship 6

Follow-Up and Monitoring

• Recognize that repeated stress without adequate support makes children progressively more vulnerable to future stressors, not more resilient 1, 6
• Adults who are socially isolated may lack standards for comparison or resources, which can exacerbate stress and increase risk for abuse 1
• If parents cannot manage the crying despite support, arrange admission to a parenting center (day stay or overnight) or local hospital 5
• Ensure successful follow-up to identify any missed diagnoses 3