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Flashcards in The irritable infant Deck (48):
1

Differential diagnosis

Periodic and related to discomfort
Cow's milk protein intolerance
GORD
Lactose overload/malabsorption
Infection- ?meningitis
Intussusception
Injury
Other sources of pain

Acute:
UTI
+ICP
OM
Hair tourniquet
Corneal abrasion
Incarcerated inguinal hernia

2

Periodic causes

Wet/dirty nappy
Too hot or too cold
Hungry
Wind
Colic
Environmental stress
Reflux esophagitis
Teething

3

Dealing with periodic

Make sure well fed, warm, has a clean nappy, comfortable clothes and a calm and peaceful environment

4

Infantile colic: definition, crying associated with (3), signs, (3), child in between

Periodic crying in first 3 months
Paroxysmal
Hunger, wind, feeding
Flushed face, tense abdomen, legs drawn up
Happy in between

5

Management of colic overview (5)

1. Engage in partnership->reassurance the infant is normal and healthy
2. Explain normal crying and sleep patterns
3. Help parents to help their baby deal with discomfort and pain
4. Assess maternal and emotional state and mother-baby relationship->coping, stress, depression
5. Provide printed information

6

Causes of abdominal pain

GIT:
Peptic ulcer
Gastroenteritis
Acute appendicitis->anorexia, central to RIF, peritonism, tachy
IBD->blood/mucus
Henoch-schonlein purpura->purpuric rash and joint pain
Constipation
Intestinal obstruction
Mesenteric adenitis
Intussusception

Urinary:
UTI
Renal colic

Endocrine:
Diabetes

Respiratory:
Lower lobe pneumonia

7

History in abdominal pain

Intermittent unexplained screaming
Blood in stool->intussusception, IBD, HSP, gastroenteritis
VD, viral, joints
Anorexia
Vomiting bile

8

What does pallor and screaming suggest

Intussusception

9

Examination in abdominal pain

General and vitals
Abdominal examination
Evidence of peritonism
If suspect mesenteric adenitis, palpable lymphadenopathy elsewhere

10

Investigations and their significance in abdominal pain

FBC->+WCC (appendicitis, UTI), anemia
Glucose->diabetes
Urine MCS->nitrates, hematuria in HSP

AXR->obstruction (dilated loops), intussusception (abnormal gas pattern), fecal loading (constipation)
Abdominal US->Renal tract abnormality, diagnosis of intussusception
CXR->pneumonia
Barium enema->intussusception
CRP/ESR->IBD

11

Differential diagnosis for iliac fossa pain

GIT:
Mesenteric adenitis
GE
Constipation
IBD

Other:
Urinary tract infection, Pyelonephritis
HSP
Ovarian pain
Ectopic

12

At what age is intussusception most common

Aged 3-24 months

13

Non surgical causes of acute abdominal pain

Gastroenteritis
PID, ectopic
UTI, pyelonephritis
DKA
Lower lobe pneumonia
HSP

14

Quick treatment of mesenteric adenitis

Analgesia

15

Presentation of colic

Extended periods of distressed behaviour
Cries ++
Repeated, sudden onset
Legs drawn up, face red
Worse in late afternoon and evening
Both sexes
Breast + bottle
Abates by 3 months in 60%, 90% by 4 months

16

Assessment of colic

Temporal association with feeds
Variation in context and environmental factors
Parental response
Supports for the parents

17

Research definition

>3 hours crying/day for >3 weeks

18

Common non-pathalogical causes of crying

+Tiredness
Hunger
Temperature

19

Average sleep requirements at birth, 2-3 months

At birth 16 hours
2-3 months 15 hours/day

20

How long after being awake does a 6 week and 3 month old baby become tired

At 6 weeks->1.5 hours
At 3 months->2 hours

21

When is hunger a more likely cause of colic

Baby has frequent feeds

22

When to suspect cow milk/soy milk protein allergy

Suspect if there is vomiting, blood or mucus in diarrhoea, poor weight gain, family history in first degree relative or signs of atopy (eczema / wheezing), significant feeding problems (especially worsening with time)

23

How is the diagnosis of cows milk allergy made and what is done

Clinical
Eliminate cow milk->modify mothers diet/changing to extensively hydrolysed formula

24

Can cow milk/soy milk protein be in breast milk

Yes

25

Is goats milk allergic

Yes, as allergenic as cows milk

26

Is silent reflux (reflux without vomiting) a likely cause of an infant crying

No

27

Does the amount of crying reflect the severity of the GORD

No

28

Role of medication in GOR

Ranitidine and omeprazole have not been shown to be effective in reducing crying
In the absence of frequent vomiting, anti-reflux medication to manage persistent infant irritability is not recommended

29

When to suspect lactose intolerance/malabsorption

Frothy watery diarrhea
Perianal excoriation

30

How is diagnosis of lactose intolerance made

presence of faecal reducing substances ≥0.5%% and pH

31

Differential for lactose intolerance in formula fed and breast fed

in breastfed babies, may be functional lactose overload (high lactose content in breast milk in babies who frequently switch breastfeeding sides +/- feed frequently ie

32

Management of lactose intolerance for formula feb and breastfed

Formula: lactose free/hydrolysed formula
Breastfed: space feeds >3 hours, empty breast at each feed and alternate sides for feeding. Consider referral to lactation consultant for feeding advice

33

If crying is acute onset, differential

If crying is of acute onset, consider:

Urinary tract infection
Otitis media
Raised intracranial pressure
Hair tourniquet of fingers / toes
Corneal foreign body / abrasion
Incarcerated inguinal hernia

34

Red flags (3)

Red flags:

1. Sudden onset of irritability and crying should not be diagnosed as colic; a specific cause is usually present

2. The maternal and family psychosocial state must be taken into account. Maternal post-natal depression may be a factor in presentation. Note that excessive crying is the most proximal risk factor for Shaken Baby Syndrome.

3. Suspect cow milk / soy protein allergy if
-vomiting / blood or mucus in diarrhoea / poor weight gain / family history in first degree relative / signs of atopy (eczema / wheezing) / significant feeding problems (especially worsening with time)
-gastro-oesophageal reflux is diagnosed
-lactose malabsorption is diagnosed in formula-fed babies

35

Algorithm for acute management: H&E, if no?, if yes?

History and examination:
-Vomiting, diarrhea
-Eczema
-Failure to thrive
-Feeding difficulties

Yes:
-Consider cows milk allergy, GORD-->consider trial of cow milk free formula/maternal diet

No:
-Medical cause unlikely-->baby tired? Hungry? Unable to self soothe?
-Colic management: discuss normal sleep and crying, settling techniques, parental support, arrange regular follow up

36

Investigations in colic

Generally not required
May consider stool examination for reducing substances and pH
Urine MCS for acute crying and vomiting
Fluroscein staining if history suggestive

37

Assisting parents to calm their baby (10)

1. Establish pattern to feeding / settling / sleep
2. Aim to settle the baby for daytime naps and night-time sleep in a predictable way (eg, quiet play, move to the bedroom, wrap the baby, give the baby a brief cuddle, then settle in the cot while still awake)
3. Avoid excessive stimulation - noise, light, handling.
4. Excessive quiet should also be avoided. Most babies find a low level of background noise soothing
5. Darken the bedroom for daytime sleeps
6. Carry baby in a papoose in front of the chest
7. Baby massage / rocking / patting
8. Gentle music
9. Respond before baby is too worked up
10. Give the mother permission to rest once a day without the need to carry out household chores. Have somebody else care for the baby for brief periods to give the parents a break.

38

Medications and treatment options for colic

1. Medication is rarely indicated.
2. Colic mixtures, gripe water etc are of no proven benefit.
3. Anticholinergic medications are not recommended due to the risk of serious adverse events (apnoeas, seizures).
4. Simethicone (Infacol Wind Drops / Degas Infant Drops) has no effect on infant crying when compared with placebo
5. Spinal manipulation= placebo
6. Formula changes are generally not helpful unless proven cow milk protein allergy

39

When to consider consulting with pediatrician

Cause unknown, appears unwell

40

Follow up

Referral within days for ongoing support is vital
Options:
-Maternal/CH nurse
-Local medical officer
-GP
-Unsettled baby clinic
-Mother-baby day unit
-Admission to hospital->if child considered at risk of non-accidental injury or parental exhaustion

41

Follow up advice to parents

See a doctor if:

You need reassurance that there is no medical cause for the crying.
Your baby is refusing feeds or is having less than half their normal feeds.
Your baby does not seem to settle with any of the things you are trying.
Your baby continues to cry for long periods.
You feel you are not coping.
You feel the crying is impacting on your relationship with your baby.
You are finding it hard to enjoy your baby or to feel positive about them.
You feel your mental health or your relationship with your partner is being affected.
OR you are worried for any other reason.

42

Cry baby checklist (10)

1. Comfort
2. Hungry
3. Dirty nappy, rash
4. Burp
5. Uncomfortable
6. Suck
7. Overtired
8. Conditions right to settle
9. Sick, fever
10. Does parent need a break

43

Red flags not associated with infantile colic, suggesting more serious condition

Fever
Lethargy
Poor feeding
Less responsive socially
Poor weight gain

44

Clinical assessment critical points in history, examination

Always ask about feeding, temperature, change in behaviour or social
responsiveness.
Are there any other symptoms to suggest serious disease e.g. vomiting, lethargy,
poor weight gain?
Never forget to examine the groin for testicular torsion or incarcerated inguinal
hernia.
If irritability is associated with a temperature, manage as "Febrile Infant".

45

One month old Tim- mother concerned as more irritable:
History

Feeding
Weight changes
Vomiting, diarrhea
Fever
Temporal relationship
What he does during the episode
How he is between crying
Mothers reactions, supports, mood

46

One month old Tim- mother concerned as more irritable: examination

Temperature
Weight gain
General observations->social interaction
Abdominal exam->ALWAYS check for incarcerated hernia

47

What to tell Tim's mother

This a well-recognised but poorly understood condition that spontaneously resolves by 3 months of age.
No long term complications
Mother may need help from friends/family
Avoid overfeeding, wind regularly, rick/carrying can help
No drugs have been shown to be safe, or help

48

John is an 8 month-old boy who 4 hours ago suddenly started crying, could not be
consoled, looked pale and grey and vomited 10 times. His irritability lasted for about 1
hour. John's mother's friend suggested that
this was infantile colic.

Wrong age
Sudden onset
Colour change and vomiting->suggestive of serious acute disorder

Intussusception
Strangulated inguinal hernia
Testicular torsion
Malrotation

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