Clinical assessment and risk stratification

Presentation

• Definition:
  • Unexplained episodes of irritability, fussing or crying that last 3 hours per day on 3 days per week for 1 week³⁸
• Hence, it is a diagnosis of exclusion.
• The typical symptoms are non-specific:
  • Inconsolable crying (typically, high-pitched and occurring frequently in the afternoon or evening)
  • Redness of the face
  • Drawing up of the knees
  • Flatus
  • In-between episodes the infant remains well and thriving

Differential diagnosis

• In the acutely distressed infant consider:
  • Physical discomfort (i.e. cold, wet, hungry)
  • Medical:
    • Sepsis
    • Severe nappy rash
  • Surgical:
    • Intussusception (especially if facial pallor instead of redness)
    • Volvulus (especially if billious vomiting)
    • Strangulated hernia
    • Testicular torsion
  • Injuries:
    • Corneal abrasion
    • Non-accidental injury
    • Hair tourniquets (digits, penis)

Image caption: USS image of an intussusception showing the classical target sign

• If symptom are severe and recurrent consider:
  • GORD (only if associated with regurgitation)
  • Constipation or dyschezia
  • Cow’s milk protein intolerance (CMPI)
  • Parental distress will also exaggerate symptoms (consider maternal postnatal depression, inadequate support or ineffective parenting skills)
  • NB: Remember isolated distressed behaviour is not a sufficient reason to investigate or treat for reflux as per the NICE guidelines².