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![Symptoms suggestive of organic causes
Extreme, prolonged and high-pitched cry
Lack of a diurnal rhythm in crying
Presence of abnormal symptoms
Positive physical examination
Persistence of crying past 4 months of age
Common office practice paediatric problems [A module of IAP Tamil Nadu state chapter 2017]](https://image.slidesharecdn.com/irritableinfant-250511031941-3c3e5053/75/irritable-infant-and-managemnent-pl-pptx-17-2048.jpg)
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irritable infant and managemnent pl.pptx
- 2. Outline Normal cry andsleep Definition Causes of cry Clinical clues Red flag signs Investigations Management Take home!
- 3. Crying – Normalpattern • Physiological behavior • 6 - 8 weeks – average 2 – 3h/24h • Worse in late afternoon or evening • Disappears by 3 - 4 months Nelson’s textbook of pediatrics 21st edn.
- 4. Average Sleep • Birth:16 - 18 h • 3 months: 14 -15h • 6 week - tired after awake for 1.5 hrs • 3 month – tired after 2 hours Nelson’s textbook of pediatrics 21st edn.
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- 6. Definition • An irritableinfant is defined as a patient younger than 1 year of age Who according to the caregiver, cries excessively or is excessively fussy. • Excessive Crying – “Rule of 3” (Wessel’s Criteria) >3 hours/day >3 days/week >3 week • Incidence - 1.5% to 11.9% Nelson’s pediatric symptom based diagnosis 2018
- 7. ETIOLOGY ENT Choanal atresia Cornealabrasion Foreign body Glaucoma Otitis media Nasal block Otitis externa Teething RS Upper Airway obstruction -croup, foreign body Lower respiratory tract infection (pneumonia, bronchiolitis) Upper respiratory tract infection CVS Congestive heart failure Supraventricular tachycardia Anomalous coronary artery Myocarditis Kawasaki disease MUSCULO SKELETAL Osteomyelitis Septic arthritis Fractures Minor soft tissue injury Discitis GUT Testicular torsion Ovarian torsion Urinary tract infection Nelson’s pediatric symptom based diagnosis 2018
- 8. GIT Incarcerated hernia Gastrointestinalobstruction (Intussusception, volvulus, pyloric stenosis, Hirschsprung disease) Abdominal trauma Peritonitis Infantile colic Constipation Uncomplicated gastroenteritis Anal fissure Gastro esophageal reflux Inappropriate feeding volume or technique Milk or soy protein allergy CNS Encephalitis Meningitis Increased intracranial pressure (trauma, hydrocephalus, intracranial haemorrhage) Intracranial mass SKIN Cellulitis Impetigo Tourniquet syndrome (digit, genitalia) Diaper Dermatitis Insect bites Minor injury MISCELLANEOUS Drug ingestion Neonatal abstinence syndrome Inborn error of metabolism Sepsis Dehydration, hypoglycemia Sickle cell crisis Physical abuse Vaccine reaction Poor caregiver-infant interaction Normal crying
- 10. Specific clinical clues Eyepain, photophobia, tearing Fever, ear tugging, otorrhoea
- 11. Coryza, fever, hoarseness, barkingcough , stridor h/o Choking, respiratory distress, decreased breath sounds on one side
- 12. Pallor ,Tachypnea, diaphoresis, disproportionatetachycardia Fever, rash, strawberry tongue
- 13. Vomiting, poor feeding,abdominal distension, guarding, palpable mass Vomiting, Testicular swelling, redness, absent cremastric reflex
- 14. Fever, Lethargy, poorfeeding, vomiting, seizures, bulging AF Poor feeding, decreased activity, fever, vomiting, skin mottling
- 15. Prolonged diaper usePattern marks to suspect inflicted injury
- 16. Nelson’s pediatric symptombased diagnosis 2018
- 17. Symptoms suggestive oforganic causes Extreme, prolonged and high-pitched cry Lack of a diurnal rhythm in crying Presence of abnormal symptoms Positive physical examination Persistence of crying past 4 months of age Common office practice paediatric problems [A module of IAP Tamil Nadu state chapter 2017]
- 18. Red Flags High-grade fever Refusalto feed / difficulty in feeding Lethargy Paroxysms of abnormal activity Unexplained bruising Sustained tachycardia > 180/min Bilious vomiting Bloody stools Paradoxical irritability / full fontanel Not moving an extremity Hiscock H, Jordan B. Problem crying in infancy. Med J Aust 2004;181
- 19. Ancillary investigations • Acomplete blood cell count with differential • ESR +/- CRP • Analysis of cerebrospinal fluid • Blood culture • Serum pH and complete metabolic panel, amylase, and lipase • Urinalysis and culture • Stool guaiac • A skeletal survey
- 20. Clinical Practice guidelinesfor unsettled or crying babies RCH 2019
- 21. Parental Counseling • ExplainNormal Patterns • Soothing strategies • Coping strategies • REST intervention REST for infants • Regulation • Entrainment • Structure • Touch REST for mothers • Reassurance • Empathy • Support • Time out for the parents Henry M.Adam, Thomas K.McInerny American Academy of Pediatrics Textbook of Pediatric Care 2nd Edn;Irritability and Fussiness:169
- 22. Medications- Little role •Pain relief – Paracetamol, ibuprofen • Antipyretics – Paracetamol • Saline nasal drops • Antibiotics – according to the infection • Anti-reflux medications PROBIOTICS • Lactobacillus reuteri • Significant reduction in crying duration in BF infants in 3 week treatment Sung V, D’Amico F, Cabana M, et al. Lactobacillus reuteri to treat infant colic: A meta-analysis. Paediatrics BMJ 2017
- 23. Medications- Little role •Dicyclomine – contraindicated (<6months) -risk of serious adverse events • Simethicone has no beneficial effect over placebo • Gripe water –AVOID (sugar or alcohol present – Ileus) • Vasambu, Omam, Uramarundu herb mixture, Asafetida, Garlic – AVOID (aspiration, infection) Metcalf TJ, Irons TG, Sher LD, Young PC. Simethicone in the treatment of infant colic: a randomized, placebo- controlled, multicenter trial. Pediatrics. 1994 Jul;94 Jain K, Gunasekaran D, Venkatesh C, Soundararajan P. Gripe Water Administration in Infants 1-6 months of Age-A Cross-sectional Study. J Clin Diagn Res. 2015;9
- 24. Take home message •Commonly benign • Can be the only presentation of a serious illness • Key - detailed history and physical exam (head to toe) • Identify ‘Red flags’ • Parental reassurance • Avoid unnecessary investigations and medications
- 25.