Crying child and approach to the child wo is irritable and crying

Approachch to crying child in paedriatic and nicu

1. CRYING CHILD –PRACTICAL APPROACH By : Dr abdul majeed

2. Babies cry because they cannot Talk ! Crying is Baby Communication !

3. INTRODUCTION Most common complaint , for which the child is brought to Pediatrician/ Primary Physician Lot many reasons why child cry ! Prevalence of excessive crying 1.5 – 40 % UK study annual cost of 108 million dollars spent by NHS on care of infants with crying & difficulty in sleeping in 1 st 12 wks alone

4. INTRODUCTION We have to differentiate when the cry is an abnormal & find out the reason behind it Each case should be looked as a clinical challenge rather than as annoyance Fear of missing a diagnosis may result in unnecessary & invasive tests

5. Introduction Crying is an important cause of maternal anxiety & stress, strongly associated with maternal depression. Can affect breast feeding Stress in relationships – mother-infant , mother- family members , mother – father relationship Can be associated rarely with physical violence

6. Acute crying –role of a physician (1 ) to avoid missing a serious or life-threatening aetiology & (2) to determine the common/treatable diagnoses .

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

8. 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. Crying …. Complaint of crying is so nonspecific, differential diagnosis is so extensive , THOROUGH HISTORY , CLINICAL EXAMINATION TOP UP WITH YOUR CLINICAL EXPERIENCE !!!

10. Systematic approach to crying patient Examine patient from head to toe literally !! General examination : temperature, pulse, respiration ( vitals ), hydration of the baby Examination of head : anterior fontanel (boggy/ depressed ) prominent veins over scalp sutural separation

11. Examination Ears : otoscopy ( AOM/ MEE) discharge from ears foreign body Nose : sinusitis bloody discharge ( foreign body ) Throat : vesicles (herpangina ) pooling of secretions ( parapharyngeal abscess)

12. Oral candidiasis

13. Examination Eyes : foreign body ,injury, intraocular pressure ( corneal enlargement in glaucoma) Neck : e/o swelling , abscess, LN suppuration Mouth : apthous ulcers, oral candidiasis, stomatitis

14. EXAMINE EYES FOR – FB, INJURY, CLOUDY CORNEA ETC

15. Examination Respiratory system : tachypnea , crepts/ bronchial breathing , e/o foreign body Per Abdomen : mass / lump in abdomen (intusseption ) , P/R exam if required Don’t forget to undress the child -- impacted inguinal hernia, torsion of testis may be missed

16. Torsion right testis Impacted lt inguinal hernia

17. INTUSUSEPTION

18. Musculoskeletal system exam Examine all bones and joints carefully to exclude fractures joints for e/o septic arthriti s

19. Examination CNS : most important to r/o Intracranial infection Examine for toxicity, see neuro behavior of the child, feeding history ,convulsions, focal neurological signs. Genitourinary system : dysuria, perivulval/perianal redness .

20. Summary of causes Head & eyes : 1. trauma 2. corneal abrasion 3. ocular/nasal/ear foreign body 4. glaucoma

21. Summary of causes Respiratory system : UR system – blocked nose acute otitis media foreign bodies LR system – bronchiolitis pneumonia foreign bodies pneumothorax

22. Summary of causes Cardiovascular : 1. congestive heart failure 2. supraventricular tachycardia 3. endocarditis , myocarditis

23. Summary of causes Gastrointestinal & genitourinary system : colic ( evening colic, colic associated with AGE, dysentery etc) Intusseption ,bowel obstruction, volvulus colitis , appendicitis Impacted feces / constipation GERD , esophagitis anal fissure.

24. Summary of causes Gastrointestinal & genitourinary system(cont.): milk protein allergy incarcerated inguinal hernia testicular torsion Urinary retention, urinary tract infection .

25. Summary of causes Musculoskeletal system : fracture osteomyelitis arthritis

26. Summary of causes Central nervous system : meningitis / encephalitis intoxication , neonatal drug withdrawal causes of raised ICP ( hydrocephalus, mass , ICH, cerebral edema pseudotumour cerebrii

27. Summary of causes Dermatologic : burns Cellulitis insect bites / urticaria atopic dermatitis .

28. treatment 1) Infants with clear diagnosis/ identifiable cause (2) infants who continue to cry without a clear, identifiable cause ---outpatient follow up visit within 24 hours ----avoidance of medicating unknown / unclear diagnosis --- reassurance and supportive measures to the parents

29. Considering special situations Consider common diagnosis first Rule out serious underlying disorders Colic has historically been defined as paroxysms of excessive crying lasting > 3 hours per day, occurring > 3 days in any week for 3 weeks, in an otherwise healthy baby aged 2 weeks to 4 months. It is estimated to affect 10% to 30% of infants worldwide.

30. Causes of colic Proposed causes include: cow’s milk protein allergy or intolerance, gastrointestinal reflux disease, feeding difficulties, sleep difficulties, and neurodevelopmental immaturity Baby parent interaction

31. For Crying Infants Criteria For Admission Toxic-appearing Hemodynamically unstable , critical illness Clinically stable with a condition requiring IV therapy (fluids, antibiotics) No access to immediate follow-up care Ongoing crying without a clear-cut etiology after examination, observation, and appropriate testing Social concerns (poor support at home, unsafe environment for the infant, risk factors for abuse or neglect) Admission criteria for crying babies

32. 1 . Well-appearing/consoled Clinically stable with a condition treatable in outpatient therapy (oral antibiotics, analgesics) 2 .Access to immediate follow-up care Resolution of crying in the ED or ongoing crying that is baseline or not concerning to provider or caregiver 3 .No social concerns Parents are comfortable with discharge plan and understand next steps regarding treatment and follow-up . Criteria for discharge from ED

33. Excuses / myths during assessment “The baby did not have a fever, so I did not consider that he could have a serious infection “Of course the baby had an elevated heart rate; he was crying The parents seem really nice, so there is no need to consider nonaccidental trauma.”

34. Excuses during assesment “All babies cry. This is a normal finding and is nothing to worry about.” ( thik ho jayega ) “The more tests I perform, the closer I will be to making a diagnosis “This baby just has colic” “Parents are always anxious about their babies, but it doesn’t mean anything is truly wrong with the infant.”

35. Carry home messages History and clinical examination …the most important tools No universally recommended lab tests/ imaging studies….. Individualize the decisions Colic & unexplained crying are the most common, than underlying serious pathologies Don’t miss underlying serious disorder

36. Summary – ’ IT CRIES’ I – Infections ( herpes stomatitis, UTI, meningitis, osteomyelitis & so forth ) T – Trauma ( accidental/non accidental ), testicular torsion C - Cardiac ( congestive cardiac failure, SVT ) R – Reflux, reaction to medications/formulas I – Immunizations, insect bites E – Eye ( corneal abrasions, FB, glaucoma) S – Surgical ( volvulus,intusseption, hernia)

37. GOOD NIGHT & HAVE SWEET DREAMS !

38. Infantile colic

39. 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 3-4 months of age

40. Infantile colic ( cont.) Episodes usually occurs during evening hours Infant may grimace, pass flatus , clench his/her fists and draw up his/her legs Cry is prolonged ,loud, high pitched – described as piercing

41. Infantile colic-- causes Colic is a diagnosis of exclusion Exact cause of colic not known , many possibilities thought of— Gastrointestinal causes Neuropsychological causes Food allergies parental misadventures

42. Infantile colic --causes a) carbohydrate malabsorption b) lactose in the diet, CMPA c) increased gas in the infants with colic ?? d) behavioral factors such as feeding abnormalities ,infant positioning while feeding e) Psychological factors suggested possible etiologies like underdeveloped parenting skills, parental anxiety, stress

43. For diagnosis of colic, routinely lab investigations are not required, unless you suspect something else

44. Factors aggravating colic Overfeeding in an attempt to lessen crying Feeding certain foods ,especially those with sugar content , may increase amount of gas in the intestines ( e.g. undiluted fruit juices ) Presence of excessive anger, fear, excitement in household Multiple factors as yet unknown

45. Treatment of infantile colic Reassuring the parents that colic is self-limited . Encourage parental rest breaks, developing strategies for crying episodes Folk remedies ( herbal teas- licorice, dill oil,fennel oil ) ?? Efficacy Behavioral modifications-positioning of infant during feeding, early response to crying – shown not to be effective

46. Treatment of infantile colic--cont Medications targeting GI system ( simethicone Vs placebo- demonstrated equal improvement) Dicyclomine has shown effect in some RCTs, but issues of safety ( apnea ,other serious adv effects) . Not recommended < 6 mths ? Changing formulas , ? Lactose free formulas ,addition of lactase in formula– No benefit

47. Low allergen diet in mother ( diet free of egg, milk, nuts, wheat, artificial colors & preservatives ). Herbal remedies ( tea containing chamomile, vervain , licorice, fennel etc) showed some reduction in crying.

48. Summary And Conclusions

49. Summary – ’ IT CRIES’ I – Infections ( herpes stomatitis, UTI, meningitis, osteomyelitis & so forth ) T – Trauma ( accidental/non accidental ), testicular torsion C - Cardiac ( congestive cardiac failure, SVT ) R – Reflux, reaction to medications/formulas I – Immunizations, insect bites E – Eye ( corneal abrasions, FB, glaucoma) S – Surgical ( volvulus,intusseption, hernia)

50. Conclusions Common clinical dilemma Every case has to be individualised History & clinical examination are main tools Ordering unnecessary test add stress to family & cost burden ! Sick child, poor growth ,inconsolable child deserves investgations Don’t forget possibility of abuse Support, reassuarance needed in many

51. IF A CHILD DOESN’T CRY ……………. …………………. ………………… …………………. …………………….. ………………………… PEDIATRICIAN MIGHT!!!

52. THANKING ALL OF YOU FOR MAKING ME SMILE!!!