child with irritability approach current.pptx

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1. Approach to the Child with Irritability Presented by : Mukose Godfrey Lecturer: Dr. MUNANURA

2. The outline Introduction  Etiologies Clinical presentation  Investigations  Differential diagnosis Management  Follow up   References

3. Introduction Definition: Irritability in children = excessive crying, fussiness, or distress disproportionate to the situation. Common in infants and young children; can signal underlying medical, environmental, or psychological issues. Early identification critical to address potentially serious conditions (e.g., infections, pain, neurological issues).

4. Epidemiology Studies have reported a percentage of all annual ED visits for infant crying ranging from 0.25% to 13.6%

5. How much does a baby cry? Normal infant crying follows typical pattern in otherwise healthy infants Progressively increases after2 weeks and peaks in second month of life, then gradually decreases by fourth or fifth month of life Peaks in late afternoon and evening within first 6months of life May occur for several hours per day May be unrelated to needs of infant and therefore difficult to soothe

6. How much should a baby sleep? Birth: 16-18 3 months: 14-15h 6 week- tired after awake for 1.5hours 3 month –tired after 2hours

7. Etiology Non pathological causes Hunger, thirst, tiredness, discomfort Separation from mother Temperature disturbances in the environment Need to clean up

8. Etiology Pathological causes of crying  Most of the diseases of neonates, infants and children have irritability as a major manifestation. For pediatrician it is important to decide the cause of irritability/crying, though difficult at times

9. Pathological

10. ETIOLOGY (IT CRIES) I infections (otitis media, sepsis, meningitis, UTI etc ) T trauma( child abuse, fractures, hair tourniquet etc ) C cardiac diseases- congenital colic, constipation R reflux, rectal/annual fissure I intersusception E eyes ( corneal abrasion, foreign body, glaucoma S skin eg diaper rash. Subdural hematoma

11. Red flag Persistent inconsolability beyond initial assessment Sudden increase in frequency or duration of inconsolability Ill appearance or abnormal vital signs Paradoxical crying(i.e. crying when handled which resolves when left undisturbed Unexplained poor growth Developmental delay Concern for trauma(e.g. fall, physical abuse Injury in precruising infants/mobile (i.e. bruises, subconjunctival hemorrhage Abdominal tenderness or distension Previous or current neurological symptoms of findings( unexplained seizures, apnea, altered mental status

12. Clinical Presentation History •  Onset, duration, and pattern of irritability (constant vs. episodic). Factors that relieve or exacerbate it •  Associated symptoms: Fever, feeding difficulties, vomiting, sleep changes. •  Triggers: Feeding, diaper changes, environmental factors. Recent changes in care arrangements •  Developmental history, recent stressors, or family history of similar issues. •  Caregiver perception.

13. Physical Examination General Appearance : Assess consolability , alertness, or lethargy. Note posture (e.g., arched back in pain, listlessness in sepsis).   Vital Signs : Check temperature (fever/hypothermia), heart rate (tachycardia), respiratory rate (distress), and oxygen saturation. Systematic exam critical in resource-limited settings to prioritize life-threatening conditions (e.g., sepsis, dehydration).

14. Physical Examination Head and Neck : •  Fontanelles (infants): Bulging (raised intracranial pressure) or sunken (dehydration). •  ENT: Inspect ears for otitis media (red, bulging tympanic membrane), throat for tonsillitis, or nasal passages for foreign bodies.

15. Physical Examination •  Neurological : Evaluate tone (hyper/hypotonia), reflexes, and consciousness level (Glasgow Coma Scale if altered). Look for meningeal signs (e.g., neck stiffness, Kernig’s sign). •  Abdomen : Palpate for distension , tenderness, or masses (e.g., intussusception). Auscultate for bowel sounds. •  Skin : Inspect for rashes (e.g., petechiae in meningitis), bruising (trauma/non-accidental injury), or pallor.

16. Physical Examination Musculoskeletal : Check for limb tenderness, swelling, or limited movement (e.g., fractures, osteomyelitis). Eyes : Assess for corneal abrasions (fluorescein staining), conjunctivitis, or abnormal pupil response (neurological concerns).

17. Diagnosis Complaint of crying is so nonspecific, differential diagnosis is so extensive, THOROUGH HISTORY, CLINICAL EXAMINATION Prioritize clinical assessment 

18. Investigations •  Tailored to suspected cause; avoid unnecessary tests. •  Basic: CBC, CRP, urinalysis, blood glucose (if infection or metabolic concerns). •  Imaging: Head ultrasound/CT (if neurological signs), abdominal X-ray (if obstruction suspected). •  Specific: Lumbar puncture (meningitis suspicion), electrolyte panel, or toxicology screen.

19. Differential Diagnosis •  Infectious : Meningitis, otitis media, urinary tract infection, sepsis. •  Gastrointestinal : Colic, intussusception, gastroesophageal reflux disease (GERD). •  Neurological : Raised intracranial pressure, seizures, migraine (older children). •  Trauma : Non-accidental injury, fractures, corneal abrasion. Other : Hypoglycemia, electrolyte imbalance, teething, hunger, or caregiver stress.

20. Infantile colic Behavioral state, characterized by unexplained paroxysms of inconsolable crying, lasting for more than 3 hrs a day & occurring more than 3 days in a week, for a period of 3 weeks. Occurs in 10-25% of infants Onset is usually 2-3 wks of age, peaking at 6-8 wks and remitting at 3-4wks

21. Management Support/Conservative •  Reassure caregivers if benign cause (e.g., colic). •  Address environmental factors: Soothing techniques (swaddling, white noise), feeding adjustments. •  Parental support: Education on normal crying patterns

22. Care giving strategies for irritable infants As Described by Dr Harvey Karp THE 5 Ss 1. swaddling 2. side or stomach holding 3. Soothing noises(shushing, singing, white noise) 4. Swinging (Slow rhythmic movement) 5. Sucking on a pacifier

23. Management Definitive Treatment •  Treat underlying cause: Antibiotics for infections, analgesics for pain, surgery for intussusception. •  Pharmacological: Antipyretics for fever, antacids for GERD (per UpToDate guidelines). •  Multidisciplinary: Involve social workers if non-accidental injury suspected.

24. Follow up Regular pediatric visits to track growth and development. Red flags: Persistent irritability, developmental delay, or recurrent episodes warrant further evaluation.

25. To Note History and clinical examination ...the most important tools No universally recommended lab tests/ imaging studies..... Individualize the decisions Don't miss underlying serious disorder

26. The References Kliegman , R. M., St. Geme , J. W., Blum, N. J., Shah, S. S., Tasker , R. C., Wilson, K. M., & Behrman , R. E. (2020). Nelson textbook of pediatrics (21st ed.). Elsevier. World Health Organization. (2013). Hospital care for children: Guidelines for the management of common illnesses with limited resources (2nd ed.). World Health Organization. https://www.who.int/publications/i/item/9789241548373 Freedman, S. B., & Rodean , J. (2024). Crying and irritability in infants: Evaluation and management. UpToDate . Retrieved August 17, 2025, from https:// www.uptodate.com /contents/approach-to-the-infant-with-excessive-crying.