Crying Child

Evaluating and managing an infant with the nonspecific complaint of excessive crying is challenging. Crying is an infant’s primary means to communicate physiologic needs (e.g. hunger) or discomfort. However, organic pathology must always be considered as a potential etiology. Considering the broad differential, and potential serious causes, an organized and detailed approach is crucial.

Initial Actions in an Infant with Excessive Crying

• Develop an initial impression.
• Perform a primary assessment.
• Conduct a secondary assessment consisting of a thorough history and physical examination focused on the presenting complaint.
• Order appropriate laboratory and imaging studies as indicated.
• Initiate therapeutic interventions directed towards correcting physiological abnormalities and treating the suspected underlying etiology.

Initial Impression

The emergency assessment of any child or infant starts with the initial impression. This is an observational assessment or “first look impression” based on the visual and auditory presentation of the patient when first encountered. The Pediatric Assessment Triangle (PAT) is a tool designed to provide health care professionals a standardized means to generate the initial impression of an ill infant or child.⁵ It is composed of three parts: work of breathing, circulation to the skin, and appearance. Characteristics of each part allow a health care professional to quickly assess if the component is normal or abnormal (see below). Once each component is assessed, combining the three provides an initial impression of the patient’s cardiopulmonary and central nervous system status. The initial impression is not designed to provide a diagnosis, rather it identifies the general category of physiologic derangement and potential severity.

Initial Assessment and the Pediatric Assessment Triangle (PAT)

Primary Assessment

The primary assessment is a structured physical assessment that proceeds in a specific order. Disorders requiring emergent management must be identified and addressed during the primary assessment.

• Airway: Assess patency - evaluate for obstruction, partial obstruction, pooling of secretions or blood.
• Breathing: Assess respiratory rate, breath sounds with auscultation, oxygen saturation.
• Circulation: Assess heart rate, pulse quality (distal and proximal), capillary refill time, blood pressure.
• Disability: Assess level of consciousness, motor activity, pupillary response.
• Exposure: Appropriate exposure of patient is necessary for complete assessment.

Secondary Assessment

The secondary assessment consists of a thorough history and physical examination focused on the presenting complaint. It should be performed only after the initial impression and primary assessment are completed and the patient is stabilized. Any life- or limb-threatening emergencies should be identified and addressed prior to initiating the secondary assessment.

• Delineate circumstances of the current condition (e.g. How long has the infant been crying? Does anything help diminish/stop the crying? What makes the crying worse?).
• Identify physical signs that are not readily apparent or subtle (e.g. hair tourniquet of the digit, corneal abrasion, otitis media).
• Create a differential diagnosis that drives diagnostic testing and subsequent management (e.g. suspicion for meningitis should prompt a lumbar puncture, cerebrospinal fluid analysis, and early antibiotic administration).

A careful secondary assessment may provide all the clues necessary to identify the cause of excessive crying in an infant or small child.

Though descriptions of excessive crying exist (largely consisting of frequency and duration), physicians must be conscious of the context and concerns described by caretakers. Frequency and duration described in studies represent mean values which might not be applicable to the individual patient of concern. It is important to elicit if the crying described by caretakers is a change from normal behavior. Physicians must also recognize that inability to console a crying infant is a component of excessive crying and should prompt a thorough evaluation.

Clinical findings assist in identifying a potential underlying etiology for excessive crying. Excessive crying and/or an inability to console an infant combined with concerning physical exam findings should prompt further laboratory and/or radiological investigation.

Presenting Signs Based on Potential Underlying Etiology

The differential diagnosis for excessive crying in an infant is broad, and the spectrum of potential problems ranges from relatively benign entities (e.g. oral thrush) to serious and life-threatening conditions (e.g. malrotation with volvulus, bacterial meningitis, sepsis).

• HEENT: Skull fracture (accidental or non-accidental trauma), glaucoma, ocular foreign body, corneal abrasion, otitis media, nasal foreign body, oral thrush, stomatitis.
• Central Nervous System: Meningitis, encephalitis, epidural hematoma, subdural hematoma, subarachnoid bleed, hydrocephalus, intracranial mass
• Cardiovascular: congestive heart failure, supraventricular tachycardia, myocarditis, anomalous origin of coronary artery.
• Pulmonary: Bronchiolitis, pneumonia.
• Gastrointestinal: Malrotation with volvulus, pyloric stenosis, appendicitis, gastroenteritis, gastro-esophageal reflux, intussusception.
• Genitourinary: Testicular torsion, urinary tract infection, incarcerated inguinal hernia.
• Musculoskeletal: Fracture, osteomyelitis, septic arthritis, dislocation, hair tourniquet of digit.
• Dermatologic: Cellulitis, abscess, insect bite or sting, anal fissure, omphalitis.
• Sepsis: Urosepsis, bacteremia.
• Non-Accidental Trauma: Intracranial injury, occult fracture(s), blunt abdominal injury.

Therapeutic interventions in the excessively crying infant are prompted by physiologic abnormalities, physical examination abnormalities, and suspected underlying cause. For example, suspicion for meningitis mandates early, broad-spectrum, intravenous antibiotics.

When pathologic causes of crying have been ruled-out by history, physical exam, and ancillary testing or imaging (see differential diagnoses), it is possible that an infant may have colic. This condition is difficult for parents due to excessive crying, but reassurance and support are crucial.6 It is important to remind families that colic is self-limited and will resolve spontaneously by three-four months of age and that the parents are not doing anything wrong or causing the crying. Another term for colic is the ‘Period of PURPLE Crying’ (Peak of crying, Unexpected, Resists soothing, Pain-like face, Long lasting, Evening). This acronym was created to emphasize education on excessive crying without an underlying cause, in an effort to prevent non-accidental trauma.^7,8

There is mixed evidence on improvement of symptoms using maternal or infant dietary changes, such as with hypoallergenic maternal diet or formula.^9-11 Other therapies and supplements, such as infant massage, probiotics, reflux medications, simethicone, or gripe water are anecdotally used but are not supported by evidence-based data.^12,13

• Crying is a common complaint in infants and is generally due to hunger or tiredness, however, more serious causes must be evaluated and managed.
• Examining the crying child is difficult and requires a skillful clinician with close attention to history and physical findings.
• Infants may have more than one pathological cause to their symptoms.
• Colic is a diagnosis of exclusion.
• Don't forget to check the diaper when it is clean.

1. Wessel MA, Cobb JC, et al. Paroxysmal Fussing in Infancy, Sometimes Called Colic. Pediatrics. 1954.
2. Wolke D, Bilgin A, Samara M. Systematic Review and Meta-Analysis: Fussing and Crying Durations and Prevalence of Colic in Infants. J Pediatr. 2017 Jun.
3. Wolke D, Samara M, Alvarez-Wolke M. Meta-Analysis of Fuss/Cry Durations and Colic Prevalence Across Countries. Proceedings of the 11th International Infant Cry Research Workshop. 2011 Jun.
4. Freedman SB, Al-Harthy N, Thull-Freedman J. The Crying Infant: Diagnostic Testing and Frequency of Serious Underlying Disease. Pediatrics. 2009 Mar.
5. Dieckman RA, Brownstein D, Gausche-Hill M. The Pediatric Assessment Triangle: A Novel Approach for the Rapid Evaluation of Children. Pediatric Emergency Care. 2010.
6. Barr RG, Rajabali F, et al. Education About Crying in Normal Infants is Associated with a Reduction in Pediatric Emergency Room Visits for Crying Complaints. Journal of Developmental Behavioural Pediatrics. 2015.
7. The Period of PURPLE Crying. National Center on Shaken Baby Syndrome. Accessed 2024 Jul.
8. Reijnevald SA, van der Wal MF, et al. Infant Crying and Abuse. Lancet. 2004.
9. Iacovou M, Ralston RA, et al. Dietary Management of Infantile Colic: A Systematic Review. Maternal and Child Health Journal. 2012.
10. Dobson D, Lucassen PL, et al. Manipulative Therapies for Infantile Colic. Cochrane Database of Systematic Reviews. 2012.
11. Hall B, Chesters J, Robinson A. Infantile Colic: A Systematic Review of Medical and Conventional Therapies. Journal of Paediatric Child Health. 2012.
12. Sung V, Collett S, et al. Probiotics to Prevent or Treat Excessive Infant Crying: Systematic Review and Meta-Analysis. JAMA Pediatrics. 2013 Dec.
13. Lam TML, Chan PC, Goh LH. Approach to Infantile Colic in Primary Care. Singapore Medical Journal. 2019 Jan.