An Evidence-Based, Systematic Approach To Acute, Unexplained, Excessive Crying In Infants

Oscar was a 14-day-old Latino baby who presented to the children's ED with the complaint of intermittent crying over the past 12 hours. His parents and aunt accompanied him, describing him as a happy baby who, since late the previous evening, had been persistently crying, except when feeding and sleeping for brief intervals. The birth and infant past histories were unremarkable and without risk factors, comorbid disease, or concomitant symptoms of acute illness. The physical examination was normal, and Oscar had continued to wail with great vigor throughout the entire encounter, until he was offered a bottle of formula, which he drank greedily. I had no explanation for the crying, but my initial impression was that of a well-appearing infant who in all likelihood did not have an immediate life- or limb-threatening problem. I explained this to the parents and aunt and recommended “some tests” to further evaluate the source of Oscar's crying. The parents thanked me for seeing the baby and stated that they, too, did not feel he was sick. They did not think it necessary to do any tests, but wanted to leave, as they had an appointment with a priest in an hour to exorcise the bad spirit that was frightening the baby. The previous afternoon, while in the neighborhood grocery, a lady had held Oscar aloft and nearly dropped him. He had thrown out his arms and legs with a loud, startled cry and it was not long after the incident that the crying episodes had begun. Patiently the interpreter and I explained how the “startle” was a normal neonatal reflex (Moro), and infants of Oscar's age do not remember frightening incidents (as far as I knew). They were insistent that they must leave, as now Oscar was once again screaming in the background. Personally I would have been relieved if Oscar had spiked a fever or suddenly had a bloody stool, because then I would know clearly how to proceed.

My dilemma with Oscar raised several interesting questions. How far should I push to keep this infant in the ED? Should I get Child Protective Services (CPS) involved, if I couldn't convince the parents to stay? Would I be justified in doing so? What laboratory or radiographic “tests” might help elucidate the cause(s) of Oscar's crying? Are there cultural differences in response to infant crying that influence infant and parental behavior? And the most important question: Can a normal, well-appearing infant present with acute, excessive crying as the sole symptom of a serious organic disease?