Radiographic and Other Studies

1. Lumbar puncture. Required in any febrile neonate (0-2 months) or any older infant or child with unexplained fever and mental status alteration to evaluate for meningitis.

2. Skeletal survey. Required in cases of suspected nonacciden-tal injury or to confirm a fracture suspected during palpation of a tender extremity.

3. CT scan of head. Required if there is any suspicion of trauma or abuse or increased ICP, or in the presence of focal neurologic signs, seizures, retinal hemorrhages, or papilledema.

4. Barium enema. Consider in infant or child with bilious emesis or other signs of obstruction.

5. pH probe. The gold standard for diagnosing gastroesophageal reflux.

6. ECG. In infants with unexplained tachycardia.

V. Plan. Complete history and careful physical exam will suggest diagnosis in most cases; only those tests that confirm a diagnosis suggested by history or exam should be performed. If the cause of crying is still unclear, additional testing may be necessary. Occasionally an infant will need an extended period of observation, requiring hospitalization or close follow-up if families are known to be reliable.

A. Infection. Treat with appropriate antibiotics.

B. Trauma. If intracranial hemorrhage is present, consult neurosurgery colleagues immediately. Cases of suspected abuse should be reported immediately to child protective service agencies and police.

C. Drugs. Avoid repeated exposure.

D. Colic. Reassurance and support is usually all that is necessary. It is crucial to evaluate parents' responses to the crying, because certain responses may inadvertently increase severity of the crying. A behavior diary can be helpful in this regard. In only a minority of colicky infants is a true protein allergy or formula intolerance actually present. If infant has other symptoms suggestive of a possible allergy, a formula change may be indicated; switch to a casein-hydrolysate formula.

E. GI Disorders. Chronic constipation should be treated aggressively with stool softeners. A trial of antacid therapy may be helpful in a crying infant with suspected gastroesophageal reflux.

F. CNS Disorders. If child has evidence of increased ICP or hemorrhage, consult neurosurgery colleagues immediately.

G. Metabolic Disorders. Treat underlying defect or its secondary effects, or both.

H. Cardiac Disorders. Treat underlying cardiac problem.

I. Behavioral Disorders. Provide reassurance and suggest behavior modification techniques. J. Anatomic Abnormalities. Consult general surgery or appropriate surgical subspecialty colleagues.

K. Toxins. Provide supportive care. Consult poison control center or toxicologist for specific interventions.

Problem Case Diagnosis. This case demonstrates the typical presentation of an infant with coli c. Patient is 3 months old, at an age when persistent crying tends to improve regardless of the mode of intervention. If elemental formula is used to treat colic, return to cow's milk-based formula later in the first year of life, unless other signs or symptoms of protein intolerance are noted.

Teaching Pearl: Question. Is formula change effective in treating infantile colic?

Teaching Pearl: Answer. Although allergic reactions to cow's milk protein have been implicated as a cause of colic, it appears that only a minority of infants benefit from a formula change.

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