A. How old is patient? Although meningitis, otitis media, gastroe-sophageal reflux disease, abuse, and other causes of irritability can occur at any age, special considerations in neonates (0-2 months of age) include colic, neonatal abstinence syndrome, metabolic disorders, and anatomic abnormalities. Colic usually begins in second or third week of life and subsides by 3-4 months of age. Persistent crying in a neonate younger than 2 weeks of age or in an older infant is unlikely to be colic.
B. What are the vital signs? Fever implies an infectious etiology. Tachycardia may be secondary to pain, fever, or volume depletion. Hypotension suggests volume depletion or septic shock.
C. What is the time course of the irritability? Acute, unexplained crying is defined as an episode lasting longer than any previous crying episode or more than 2 hours. Although infectious disease appears to be the most common cause, initially consider a broad differential diagnosis. Long-standing or chronic, persistent crying suggests colic, gastroesophageal reflux, milk-protein allergy, increased intracranial pressure, abuse, or an underlying metabolic problem.
D. Is there a history of trauma? Infants with subdural hematomas may present with persistent crying and not have altered mental status or seizures. Crying may also be the only clue to a long bone fracture. Clues to the diagnosis of nonaccidental injury include a history that does not adequately explain the injuries and evidence of a chaotic social situation (see Chapter 14, Child Abuse: Physical, p. 69).
E. Any history of prenatal drug exposure? Consider in neonates with signs and symptoms suggestive of withdrawal (eg, irritability, tachycardia, diaphoresis, and diarrhea).
F. What medication(s) does patient take? If child is being breastfed, it is also important to know what medication(s) mother is taking. Antihistamines and corticosteroids can cause paradoxical CNS stimulation in young infants. Decongestants can cause irritability and insomnia. Consider accidental ingestion or environmental toxin in a toddler with irritability and change in mental status.
G. Are there any associated symptoms to suggest GI pathology? In a young infant, this would include poor weight gain, vomiting, crying, arching or posturing after feeding, recurrent wheezing or pneumonia, apnea, flatulence, diarrhea, constipation, or an abdominal or inguinal mass.
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