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  • The infant cry may signal hunger, an unmet need for attention, or a diaper change, or crying may signal distress or pain.
  • An infant not interacting with the parents appropriately is toxic and has a serious reason for his or her crying. Note the pitch of the cry, as this is important and will help the clinician decide the direction of the assessment.
  • It is important to observe the infant for at least 1 to 2 hours if one has not identified the cause. If after this period of observation, the crying abates, the infant may be sent home with close follow-up with the primary care physician. If the crying persists, the clinician should proceed with a more complete workup and have the infant admitted for observation.


The assessment of the acutely crying infant in the emergency department (ED) is difficult because the infant can be disruptive as the parents are usually overwhelmed, and the crying is distractive to the ED staff. Given these challenges, the clinician must resist the urge to rush through the history and physical examination. Instead, the clinician must be deliberate in their search for the cause, since the clues to the diagnosis may be subtle. The clinician should perform serial observations and examinations until the cause is found or infants return to their normal baseline behavior. Fortunately, with a thorough history, a meticulous physical examination, limited diagnostic tests, and a period of observation in the ED, most of the diagnoses of the crying, irritable infant are identified.1


To unravel the cause of acute, unexplained crying, it is important to know what normal infant crying encompasses and the definition of colic. Crying is part of normal psychomotor and psychosocial development and is the infant's source of communication. The infant cry may signal hunger, an unmet need for attention, or a diaper change, or crying may signal distress or pain.


The normal crying pattern in the first year of life has been described.2 There is a progressive increase in crying, which peaks in the second month of life and then gradually decreases.2,3 The peak crying time may be as much as 2 to 3 hours per day at 6 weeks of life.4 When the infant has other ways to communicate, such as interacting with a social smile, the daily crying time decreases. Infant crying time has been reported to usually decrease to 1 hour a day by 14 weeks of age (3.5 months).5


Colic is a chronic crying syndrome in the first 3 months of life. Colic has been described as unexplained, paroxysmal crying in healthy, well-fed infants with normal weight gain. Colic starts around 3 weeks of age and continues till the infant is 3 months old. A typical colic episode is when infants suddenly flex their legs, their face turns red, and the parents report that the infant expels a lot of flatus. ...

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