Crying Or Fussing Child

Introduction

Understanding how to approach a crying or fussing child is crucial for Canadian medical practitioners preparing for the MCCQE1 exam. This comprehensive guide will cover the essential aspects of this topic, tailored specifically for the Canadian healthcare context and the MCCQE1 preparation.

Epidemiology in the Canadian Context

• Approximately 15-25% of infants in Canada experience excessive crying or fussiness
• Peak incidence occurs between 6-8 weeks of age
• More common in first-born children and those with a family history of colic

Etiology and Risk Factors

Clinical Presentation and Assessment

Key Symptoms

• Excessive crying (>3 hours/day, >3 days/week, for >3 weeks)
• Inconsolability
• Drawing up of legs
• Clenched fists
• Facial flushing

Canadian Triage and Acuity Scale (CTAS) Considerations

Physical Examination

Differential Diagnosis

1. Colic
2. Gastroesophageal reflux disease (GERD)
3. Cow's milk protein allergy
4. Otitis media
5. Urinary tract infection
6. Intussusception
7. Child abuse or neglect

Management Strategies

Non-pharmacological Interventions

• Swaddling
• White noise
• Gentle rocking
• Pacifier use
• Feeding adjustments (if breastfeeding)

Pharmacological Interventions

• Simethicone drops (limited evidence)
• Probiotics (Lactobacillus reuteri DSM 17938)
• Pain relief (acetaminophen or ibuprofen) if an underlying painful condition is identified

Canadian Guidelines and Best Practices

The Canadian Paediatric Society (CPS) provides the following recommendations:

1. Encourage parents to keep a crying diary to identify patterns
2. Promote safe sleep practices while managing crying
3. Educate parents about normal crying patterns and coping strategies
4. Screen for postpartum depression in mothers of excessively crying infants
5. Refer to community support services when appropriate

Key Points to Remember for MCCQE1

• Differentiate between normal crying and pathological causes
• Know the "Rule of 3s" for defining colic
• Understand the importance of a thorough physical examination
• Be familiar with the CTAS system for triaging crying infants
• Recognize red flags that suggest serious underlying conditions
• Be aware of the limited evidence for pharmacological interventions
• Emphasize parental education and support in management plans

Sample Question

A 6-week-old male infant is brought to the emergency department by his parents due to excessive crying. The parents report that the baby cries for about 4 hours every evening, draws his legs up to his abdomen, and seems inconsolable. The crying episodes have been occurring for the past 2 weeks. The infant is growing well and feeding normally. Physical examination is unremarkable. Which one of the following is the most appropriate next step in management?

• A. Prescribe simethicone drops
• B. Order abdominal ultrasound
• C. Recommend switching to hypoallergenic formula
• D. Provide reassurance and education on colic
• E. Refer to a pediatric gastroenterologist

Explanation

The correct answer is:

• D. Provide reassurance and education on colic

This infant's presentation is consistent with colic, which is defined as crying for more than 3 hours per day, more than 3 days per week, for at least 3 weeks in an otherwise healthy baby. The symptoms typically peak around 6-8 weeks of age. In the absence of any concerning findings on physical examination and with normal growth and feeding, reassurance and education are the most appropriate next steps. Parents should be informed about the self-limiting nature of colic and taught coping strategies.

Option A (simethicone drops) is incorrect as there is limited evidence for its effectiveness in colic. Option B (abdominal ultrasound) is not indicated without any signs of abdominal pathology. Option C (hypoallergenic formula) is not appropriate as the first step, especially if the infant is growing well. Option E (referral to a gastroenterologist) is unnecessary for uncomplicated colic.

References

1. Canadian Paediatric Society. (2021). Colic and crying. Retrieved from https://www.cps.ca/en/documents/position/colic-and-crying (opens in a new tab)
2. Sung, V., et al. (2018). Probiotics to prevent or treat excessive infant crying: systematic review and meta-analysis. JAMA Pediatrics, 172(6), 534-542.
3. Freedman, S. B., et al. (2017). Pediatric Canadian Triage and Acuity Scale: Implementation and Its Impact on Emergency Department Length of Stay. Annals of Emergency Medicine, 70(5), 648-658.