Evaluation of Afebrile Crying Infants
The Crying Infant: Diagnostic Testing and Frequency of Serious Underlying Disease.
Freedman SB, Al-Harthy N, Thull-Freedman J. Pediatrics 2009; 123(3):841-848
Colic or excessive crying is a common presenting complaint for infants in the Emergency Department. Evaluation of the crying infant can be challenging, particularly when the child does not have a fever and cannot be stratified using existing clinical decision making tools. As there have been few studies examining how often excessive crying in afebrile infants is caused by serious illness, this article intended to determine the frequency of dangerous underlying etiology requiring emergent diagnosis.
The study is a single center retrospective review of consecutive visits of afebrile infants presenting with a chief complaint of crying. The study site is a pediatric ED that has >50,000 visits per year.
Charts were reviewed for infants less than a year old presenting with a chief complaint consistent with excessive crying (“cry,” “irritable,” “colic,” etc) who did not have a fever documented at home or in the ED. Tactile fever was considered afebrile. Variables analyzed included history and physical, lab tests, imaging, and whether the general appearance of the child was well/unwell/unclear. Each encounter had a follow up phone call made 9-18 months after index visit.
The primary outcome was what proportion of infants had a serious underlying etiology that would require emergent diagnosis and treatment. Illnesses that would be considered “serious” were defined before the chart review was begun. The secondary outcome was what proportion of children who had a serious illness that was not suspected based on the history and physical alone, and whether there were any particular tests that should routinely be performed on afebrile crying infants.
237 infants were enrolled in the study, of which 12 (5%) were found to have a diagnosis that had been defined by the study authors as a serious illness. 10 (83%) of these were diagnosed at the initial ED visit, and the other 2 (17%) were diagnosed after. UTI was the most common infection.
More than half (66.4%) of study subjects had findings in the initial history and physical that were suggestive of the final diagnosis. Of infants who were well appearing and unclear history/physical, more extensive testing revealed illness in only 2 (0.8%) patients. Both of these were UTI’s.
Serious illness found in study subjects were acute cholecystitis, acute lymphoblastic leukemia, clavicle fracture (2), epidural hematoma, intussusception, nephrolithiasis, pulled elbow, spinal muscular atrophy, and UTI (3).
5% of afebrile crying infants in this study had a serious illness which confirms careful evaluation of these patients is important, however given <1% were diagnosed based on laboratory/radiologic testing alone a workup based on the clinical picture seems appropriate. These results also emphasize the importance of obtaining a complete history and thorough physical exam of the crying infant. As the most common infection in this study group was UTI, obtaining a urine sample may be a high yield and minimally invasive test to perform in these investigations, though more extensive evaluation should not routinely be performed without clinical indication.