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* This is the Professional Version. *


by Deborah M. Consolini, MD

All infants and young children cry as a form of communication; it is the only means they have to express a need. Thus, most crying is in response to hunger, discomfort (eg, a wet diaper), or separation, and it ceases when the needs are met (eg, by feeding, changing, cuddling). This crying is normal and tends to lessen in duration and frequency after 3 mo of age. However, crying that persists after attempts to address routine needs and efforts to console or that is prolonged in relation to the child’s baseline should be investigated to identify a specific cause.


Cause of crying is

  • Organic in < 5%

  • Functional in 95%


Organic causes, although rare, must always be considered. Causes to consider are classified as cardiac, GI, infectious, and traumatic (see Some Causes of Crying). Of these, potential life threats include heart failure, intussusception, volvulus, meningitis, and intracranial bleeding due to head trauma.

Colic (see Colic) is excessive crying that occurs in infants ≤ 4 mo of age, that has no identifiable organic cause, and that occurs at least 3 h/day > 3 days/wk for > 3 wk.

Some Causes of Crying


Suggestive Findings

Diagnostic Approach


Coarctation of the aorta

Delayed or absent femoral pulses




Poor feeding

Systolic ejection murmur, systolic click

Chest x-ray



Heart failure




Poor feeding

S 3 gallop

Chest x-ray



Supraventricular tachycardia




Poor feeding

Heart rate > 180 beats/min (usually 220–280 beats/min in infants; 180–220 beats/min in older children)

Chest x-ray




Anal tears or fissures

History of decreased stool frequency and hard pellet stools

Distended abdomen

Clinical evaluation


Hyperactive bowel sounds

Loose, frequent stools

Clinical evaluation

Gastroesophageal reflux

History of spitting up, arching, or crying after feedings

Swallowing study

Esophageal pH or impedance probe study


Severe colicky abdominal pain alternating with calm, pain-free periods



Currant-jelly stools

Abdominal x-ray

Air enema

Cow's milk protein intolerance (milk protein allergy)


Diarrhea or constipation

Poor feeding

Failure to thrive

Stool heme test


Bilious vomiting

Tender, distended abdomen

Bloody stools

Absent bowel sounds

Abdominal x-ray

Barium enema

Incarcerated hernia

Tender, erythematous mass in groin

Clinical evaluation




Inconsolability, irritability


Bulging anterior fontanelle in infants

Meningismus in older children

Lumbar puncture for CSF testing

Otitis media


Pulling at ears or complaints of ear pain

Erythematous, opaque, bulging tympanic membrane

Clinical evaluation

Respiratory infection (bronchiolitis, pneumonia)



Sometimes hypoxia

Sometimes wheezing, rales, or decreased breath sounds on auscultation

Chest x-ray



Possible vomiting

Urinalysis and culture


Corneal abrasion

Crying with no other symptoms

Fluorescein test

Fracture (abuse)

Area of swelling and/or ecchymoses

Favoring of a limb

Skeletal survey x-rays to check for current and old fractures

Hair tourniquet

Swollen tip of a toe, finger, or penis with hair wrapped around the appendage proximal to the swelling

Clinical evaluation

Head trauma with intracranial bleeding

Inconsolable, high-pitched cry

Localized swelling on skull with underlying deformity

Head CT

Shaken baby syndrome

Inconsolable, high-pitched cry


Seizure activity

Head CT

Retinal examination

Skeletal survey


Cold drugs

History of recent cold drug therapy

Clinical evaluation

Testicular torsion

Swollen erythematous asymmetric scrotum, absent cremasteric reflex

Doppler ultrasonography or nuclear scanning of the scrotum

Vaccine reaction

History of recent immunization

Clinical evaluation

S 3 = 3rd heart sound.



History of present illness focuses on onset of crying, duration, response to attempts to console, and frequency or uniqueness of episodes. Parents should be asked about associated events or conditions, including recent immunizations, trauma (eg, falls), interaction with a sibling, infections, drug use, and relationship of crying with feedings and bowel movements.

Review of systems focuses on symptoms of causative disorders, including constipation, diarrhea, vomiting, arching of back, explosive stools, and bloody stools (GI disorders); fever, cough, wheezing, nasal congestion, and difficulty breathing (respiratory infection); and apparent pain during bathing or changing (trauma).

Past medical history should note previous episodes of crying and conditions that can potentially predispose to crying (eg, history of heart disease, developmental delay).

Physical examination

Examination begins with a review of vital signs, particularly for fever and tachypnea. Initial observation assesses the infant or child for signs of lethargy or distress and notes how the parents are interacting with the child.

The infant or child is undressed and observed for signs of respiratory distress (eg, superclavicular and subcostal retractions, cyanosis). The entire body surface is inspected for swelling, bruising, and abrasions.

Auscultatory examination focuses on signs of respiratory infection (eg, wheezing, rales, decreased breath sounds) and cardiac compromise (eg, tachycardia, gallop, holosystolic murmur, systolic click). The abdomen is palpated for signs of tenderness. The diaper is removed for examination of the genitals and anus to look for signs of testicular torsion (eg, red-ecchymotic scrotum, pain on palpation), hair tourniquet on the penis, inguinal hernia (eg, swelling in the inguinal region or scrotum), and anal fissures.

Extremities are examined for signs of fracture (eg, swelling, erythema, tenderness, pain with passive motion). Fingers and toes are checked for hair tourniquets.

The ears are examined for signs of trauma (eg, blood in the canal or behind the tympanic membrane) or infection (eg, red, bulging tympanic membrane). The corneas are stained with fluorescein and examined with a blue light to rule out corneal abrasion, and the fundi are examined with an ophthalmoscope for signs of hemorrhage. (If retinal hemorrhages are suspected, examination by an ophthalmologist is advised.) The oropharynx is examined for signs of thrush or oral abrasions. The skull is gently palpated for signs of fracture.

Red flags

The following findings are of particular concern:

  • Respiratory distress

  • Bruising and abrasions

  • Extreme irritability

  • Fever and inconsolability

  • Fever in an infant 8 wk of age

Interpretation of findings

A high index of suspicion is warranted when evaluating crying. Parental concern is an important variable. When concern is high, the clinician should be wary even when there are no conclusive findings because the parents may be reacting subconsciously to subtle but significant changes. Conversely, a very low level of concern, particularly if there is lack of parental interaction with the infant or child, can indicate a bonding problem or an inability to assess and manage the child’s needs. Inconsistency of the history and the child’s clinical presentation should raise concerns about possible abuse.

It is helpful to distinguish the general area of concern. For example, with fever, the most likely etiology is infectious; respiratory distress without fever indicates possible cardiac etiology or pain. Abnormalities in stool history or abdominal pain during examination is consistent with a GI etiology. Specific findings often suggest certain causes (see Some Causes of Crying).

The time frame is also helpful. Crying that has been intermittent over a number of days is of less concern than sudden, constant crying. Whether the cry is exclusive to a time of day or night is helpful. For example, recent onset of crying at night in an otherwise happy, healthy infant or child may be consistent with separation anxiety or sleep association issues.

The character of the cry is also revealing. Parents frequently can distinguish a cry that is painful in character from a frantic or scared cry. It is also important to determine the level of acuity. An inconsolable infant or child is of more concern than an infant or child who is well-appearing and consolable in the office.


Testing is targeted at the suspected cause (see Some Causes of Crying) and pays particular attention to potential life threats, unless the history and physical examination are sufficient for diagnosis. When there are few or no specific clinical findings and no testing is immediately indicated, close follow-up and reevaluation are appropriate.


The underlying organic disorder should be treated. Support and encouragement are important for parents when the infant or child has no apparent underlying disorder. Swaddling an infant in the first month of life can be helpful. Holding an infant or child is helpful in decreasing the duration of crying. It is also valuable to encourage parents, if they are feeling frustrated, to take a break from a crying baby and put the infant or child down in a safe environment for a few minutes. Educating parents and “giving permission” to take a break are helpful in preventing abuse. Supplying resources for support services to parents who seem overwhelmed may prevent future concerns.

Key Points

  • Crying is part of normal development and is most prevalent during the first 3 mo of life.

  • Excessive crying with organic causes needs to be differentiated from colic.

  • Less than 5% of crying has an organic cause.

  • When no organic cause is identified, parents may need support.

Resources In This Article

* This is a professional Version *