Most prolonged crying in well-appearing infants is colic, but 'crying' is a chief complaint that hides life threats. Use the IT CRIES mnemonic to systematically exclude dangerous causes before diagnosing colic.
🚩 Red-flag clues (must not miss)
- •Hair tourniquet on digit / penis / clitoris — fully undress to find
- •Corneal abrasion (FL stain) — often missed
- •Bilious vomiting → malrotation/volvulus
- •Currant-jelly stool, sausage mass = intussusception
- •Bruising in pre-ambulatory infant ('those who don't cruise rarely bruise') = NAT
- •Bulging fontanelle / retinal hemorrhages = abusive head trauma
History
- Onset, duration, pattern (paroxysmal vs constant)
- Feeding tolerance, vomiting (bilious?), stool changes
- Fever, URI, ear pulling, recent immunizations
- Family stress, caregiver coping (link to NAT risk)
Exam
- Full skin exam (undress completely): tourniquets, bruises
- Eyes: fluorescein for abrasion
- Ears, oropharynx, fontanelle, genitalia (testes), hernia sites
- Abdomen, extremities (pull on each digit, palpate long bones)
Differential & next step
| Diagnosis | Clue | Next step |
|---|---|---|
| I — Infection | Fever, UTI in infant | UA + cx, sepsis w/u if < 3 mo |
| T — Trauma / NAT | Bruising, retinal heme | Skeletal survey, head CT (without contrast), social work |
| T — Tourniquet (hair) | Swollen digit/penis | Remove with depilatory or cut |
| C — Cardiac (SVT, anomalous coronary) | Diaphoresis with feeds, HR > 220 | ECG, adenosine if SVT |
| C — Corneal abrasion | Tearing, photophobia | Fluorescein, topical abx |
| R — Reactions / Reflux | Vaccines, formula intolerance | Reassurance vs trial change |
| I — Intussusception | Episodic, currant-jelly stool | US → air-contrast enema |
| I — Incarcerated hernia | Tender groin mass | Reduce; surgery consult |
| E — Eye (FB, glaucoma) | Photophobia, cloudy cornea | Ophthalmology |
| S — Strangulation (testicular torsion) | Tender, high-riding testis | Emergent urology, US Doppler |
| S — Surgical (volvulus, NEC) | Bilious emesis, distention | NPO, NG, surgery |
Management / next steps
- Full undressing, head-to-toe exam — repeat if no source found
- Vital signs in age-appropriate range; trial of feeding
- If well-appearing & exam normal after thorough search → colic, return precautions
- If any red flag → admit / observe / specialty consult
Source: https://fprmed.com/fprmedcom/Pages/Pedi/Crying_baby.html
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