• Intussusception
• Gastroesophageal reflux
• Volvulus
• Gaseous distension (2° to improper feeding or burping)
• Incarcerated hernia
• Peritonitis (acute abdomen)
• Testicular/ovarian torsion
• Constipation
• Anal fissure
• Meatal ulceration
• Glaucoma

• Otitis media/externa
• Urinary tract infection
• Stomatitis
• Meningitis
• Gastroenteritis
• Arthritis
• Osteomyelitis
• Balanitis
• Dermatitis (especially pruritic as in scabies or painful as in staphylococcal scalded skin syndrome)

• Neonatal drug withdrawal
• Prenatal/perinatal cocaine exposure
• Immunization reactions (especially DTP)
• Milk intolerance
• Drug reactions (especially antihistamines, pseudoephedrine, phenylpropanolamine), including maternal medications in breast milk
• Vitamin A toxicity
• Emotional/physical neglect

• Corneal abrasion
• Foreign body (hypopharynx, eye, ear)
• Skull fracture/subdural hematoma
• Intracranial hemorrhage
• Retinal hemorrhage
• Other fractures (especially extremities)
• Hair tourniquet syndrome (encircling finger, toe, penis, clitoris)
• Open diaper pin
• Bite (human, animal, insect)

• Sickle cell crisis
• Phenylketonuria
• Hypoglycemia
• Electrolyte abnormalities (especially sodium)
• Hypoglycemia
• Hypocalcemia
• Inborn error of metabolism

• Cow milk allergy
• Celiac disease

• Parental expectations/responses

• Overstimulation
• Persistent night awakening
• Night terrors
• Congestive heart failure
• Caffey disease (infantile cortical hyperostosis)
• Dysrhythmia (especially supraventricular tachycardia)
• Autism
• Teething
• Headache
• Temperament
• Colic
• Discomfort (cold, heat, itching, hunger)

Question: Onset after 1 month of age or persistent in infants older than 4 months?
Significance: Colic less likely as a cause.

Question: First episode?
Significance: Recurrent episodes, particularly with a diurnal pattern, are more likely due to colic.

Question: Fever?
Significance: Potential need for evaluation of meningitis, other infections.

Question: Do attempts at consolation make the crying worse?
Significance: Paradoxically increased crying (especially with lifting, rocking) can be seen in meningitis, peritonitis, long-bone fractures, arthritis.

Question: Stridor?
Significance: Implies possible upper airway obstruction (mechanical, functional).

Question: Expiratory grunting?
Significance: Higher likelihood of significant pathologic cause of crying (especially cardiac, respiratory, and/or infectious disease).

Question: Cold symptoms and/or day care attendance?
Significance: Increased likelihood of otitis media.

Question: Vomiting?
Significance: Higher likelihood of pathologic gastrointestinal cause (e.g., obstruction, G-E reflux with possible esophagitis), particularly in infant <3 months, or CNS disease.

Question: What is the pattern of feeding?
Significance: Over/underfeeding, excessive air swallowing, inadequate burping, improper formula preparation may contribute to excessive crying.

Question: Recent fall or trauma?
Significance: Possible fracture, increased intracranial pressure, abuse.

Finding: Tympanic membrane with loss of landmarks, poor mobility.
Significance: Otitis media

Finding: Tenderness on palpation of extremities or clavicle.
Significance: Suggests fracture or osteomyelitis.

Finding: Conjunctival redness
Significance: Suggests corneal abrasion (fluorescein testing of eye warranted) or foreign body in eye (eversion of lid recommended)

Finding: Impacted or bloody stool on rectal exam, abdominal mass
Significance: Constipation or intussusception

Finding: Geographic scars, frenulum tears, retinal hemorrhages, suspicious bruises, decreased weight/height ratio
Significance: Neglect/abuse (physical, emotional)

Finding: Bulging fontanel
Significance: Possible increased ICP (meningitis, subdural hematoma, vitamin A toxicity)

Finding: Edema of individual toes or fingers
Significance: Hair tourniquet syndrome

Finding: Tender swelling in inguinal or scrotal area
Significance: Incarcerated hernia, testicular torsion

Finding: Heart rate >200 with minimal variability
Significance: Possible supraventricular tachycardia

Test: Stool for occult blood
Significance: Possible intussusception, anal fissure

Test: Fluorescein testing of eye
Significance: Corneal abrasion (may occur without significant conjunctival redness)

Test: Urinalysis/urine culture
Significance: Urinary tract infection

Test: Urine toxicology screen
Significance: Drug withdrawal (neonatal), ingestions, passive exposures (e.g., cocaine)

Factors that make this an emergency include:

• Suspicion of meningitis: stiff neck, bulging fontanel, fever (especially infants <2 to 3 months)
• Suspicion of intestinal obstruction: vomiting (especially bilious or projectile), mass on abdominal palpation, and/or bloody stools
• Suspicion of incarcerated hernia or testicular/ovarian torsion
• Evidence of cardiac compromise (CHF, SVT): tachycardia, poor perfusion (capillary refill >3 seconds, poor distal pulses), rales
• Evidence of acute dehydration: weight loss, decreased urine output, orthostatic changes, poor perfusion
• Evidence of child abuse or neglect

Q: What is the most likely cause of inconsolable crying in the first few months of life?
A: Without question, infantile colic. A practitioner needs to be familiar with the clinical pattern of infantile colic, so that deviations from this most common pediatric syndrome are readily recognized.

Q: Is teething a common cause of excessive crying?
A: Grandmothers everywhere insist that it is (as well as a common cause of fever, diarrhea, rashes, etc.). Objective data do not support a strong association. Be careful in ascribing symptoms and signs to teething. Trust the grandmothers, but verify.

Factors that may help alert you to make a referral include: Ill versus well-appearing. Although observation alone is less reliable in infants <3 months, judgement of an infant to be ill-appearing (e.g., pallor, grunting, poor arousability, poor response to social overtures) warrants more urgent and extensive evaluation. Weight loss implies a much higher likelihood of an organic cause of repetitive bouts of crying.

• Quality of cry: Objective acoustic analyses of cries may become a common future modality to distinguish pathologic from physiologic crying. However, subjective interpretation can be helpful.
  • High-pitched (shrill, piercing) crying in short bursts: associated with CNS pathology, especially with increased intracranial pressure
  • High-pitched crying in longer bursts: seen in SGA infants, neonatal drug withdrawal
  • Hoarse crying: seen in hypothyroidism, laryngeal diseases, hypocalcemic tetany
  • Weak crying: may be seen in neuromuscular disorders, such as Hoffman-Werdnig syndrome, infant botulism, and/or the very ill infant
  • Cat-like cry: as noted on every pediatric board exam for the last 35 years, a mewing cry can be associated with cri du chat syndrome (5p syndrome or absence of short arm of chromosome 5)
• Neonatal drug withdrawal has other characteristic findings in addition to excessive crying.

W Wakefulness

I Irritability

T Tremulousness, temperature variation, tachypnea

H Hyperactivity, high-pitched persistent cry, hyperacusis, hyperreflexia, hypertonia

D Diarrhea, diaphoresis, disorganized suck

R Rub marks, respiratory distress, rhinorrhea

A Apnea, autonomic dysfunction

W Weight loss or failure to gain weight

A Alkalosis (respiratory)

L Lacrimation

Committee on drugs: neonatal drug withdrawal. Pediatrics 1998;101(6)72:1079–1088.

Corwin MJ, Lester BM, Golub HL. The infant cry: what can it tell us? Curr Probl Pediatr 1996;26(9):325–334.

Poole SR. The infant with acute, unexplained, excessive crying. Pediatrics 1991;88(3):450–455.