May 26, 2011
IDENTIFYING THE CAUSE OF IRRITATION IN A CEASELESSLY CRYING BABY
What do you do to console a three month old baby who has been crying tirelessly for about one week? Her mother reported that even breastfeeding was not able to console the child, who cried intermittently even while breastfeeding. By this time, her mother had joined in crying also, and we had both mother and child crying at presentation at the consulting clinic. Who do you console first, and what do you do to gain the trust of the wailing mother that her dear baby girl was not in any grave danger. Keywords: Crying baby, wailing mother, cause of crying. Corresponding Author: Dr. E. B. Anyanwu. Department of Family Medicine, Delta State University Teaching Hospital, Oghara. P.O. Box 7, Oghara, Delta State Nigeria. E-mail: ebirian[@]yahoo.com Tel: +2348035701711 Case Presentation A young mother brought in her three month old baby girl with the history that the baby has been crying excessively for about one week without any known reasons. There was no history of fall given by her mother. No history of fever, no diarrhea and no convulsion reported. The child has been passing urine normally and apparently she had a soul appetite. Her mother reported that she has noticed that the baby has been pulling on her ears repeatedly. There was neither ear discharge noted nor any offensive odour from her ears. She was said to have vomited once. She was up-to-date with her immunization schedule. The baby had not responded to all the consolation offered by her mother. Not even the act of breastfeeding, an act the baby enjoyed before the present state, stopped the excessive crying. Even while breastfeeding the baby cries intermittently. Her sleep at night had also been disturbed. Soon after, her mother also started crying not knowing what next to do to stop her baby from crying too much. Intermittently during the office consultation, the baby will start to cry and her mother joins in, thereby breaking the sequence of the interview. Examination revealed a non-febrile, healthy looking baby girl, who was not pale, well hydrated and not jaundiced nor cyanosed. She was however very irritable, crying even without any stimulus. The systemic examination was essentially normal. The anterior fontanel was normotensive, neck was supple. She moves all four limbs well though irrationally. The ear examination revealed inflamed, reddish tympanic membrane of both ears. There was no discharge, and no ear wax noted. A working diagnosis of an irritable child ?secondary to bilateral otitis media was made and admission was offered to her mother, who readily agreed for the admission. Laboratory investigations were ordered and results were as follows: White blood cells = 11,000/mm3 (4,800 – 11,000) Neutrophile = 57% Lymphocyte = 43% Haemetocrite = 28% Malaria Parasite = Nil Random blood sugar = 112mg% Cerebro-spinal fluid analysis = normal Intravenous injection of an appropriate antibiotic was started for the child and gradually over a period of three days, the girl improved and the irritability decreased dramatically. She was discharged home on the third day of admission no longer crying and her mother happy. Discussion An inconsolably crying child presents a diagnostic dilemma, in as much as the baby cannot communicate with you. The issues at hand are even made worse if the pressure has been transmitted to the parents of the baby, who should have been more alert and sensitive to the baby’s situation. This usually leaves the clinician with virtually nothing to start with and then the needs to start a comprehensive search for the possible causes of the presenting baby’s illness. The presenting baby was reported to have started crying inconsolably over a period of about one week. No fever was reported. Baby was still very active and her mother felt initially that the baby was not getting enough “food” from the breast milk since the baby was being exclusively breastfed. She then resorted to breastfeeding the baby more frequently, but this did not help matters as the child continued to cry as much as before. The mother who was greatly alarmed by this time felt that maybe her breast milk had gone “sour” and that the baby was rejecting both herself and the “soured” breast milk. It was at this point that she broke down and started crying alongside the crying baby. She was completely devastated by her baby that her breast milk has gone sour. Unfortunately, she had some elderly women in her community who agreed with her that the ‘soured’ breast milk was responsible for the baby crying so much and for so long. The introduction of complementary feeding did not help matter as the baby vomited the initial feeding and was still irritable. The grandmothers around her then suggested that the problem was “abnormal colic” and gripewater first and nospamin latter were introduced, again to no avail. The mother’s state now was that of total confusion. Irritability in a child was most commonly attributed to cerebro – spinal infections but many other conditions can cause it. Such other conditions include hypoglycemia, simple and complicated malaria, otitis media, urinary tract infection and pulmonary infection. A thorough systemic examination only showed features of bilateral otitis media. A lumbar puncture for cerebro-spinal fluid analysis was essentially normal, thereby ruling out any central nervous system infection. Malaria parasite smear that was done was negative for malaria parasite. It is known that malaria fever caused by plasmodium falciparum can cause severe and complicated malaria (1) which can present with irritability. The young girl however did not have any history of convulsion, neither was she obtunded. She was fully conscious and there was no change in her sensorium. Malaria fever can also cause hypoglycaemia, (2 – 4) which can also present with irritability and changes in sensorium. There may be episodes of convulsions and if not properly treated, patients may lapse into coma. Otitis media is a known cause of irritability in children, and the baby’s mother reported that the baby was noted to have been pulling on her ears. But in the absence of signs and symptoms, ear tugging alone is a poor indicator of acute otitis media (5,6). The commonest bacterial agents previously isolated from middle ear fluid cultures are Streptococcus pneumoniae (43%), Moraxella catarrhalis (21%), Haemophilus influenza (18%) and Respiratory syncytial virus (7%) and Rhinovirus (3%) (6). The most dangerous immediate complications of acute otitis media involve local suppurative spread to structures within the temporal bone and beyond into other compartments of the cranial vault, causing such conditions as mastoiditis, labyrinthitis, facial nerve paralysis, osteomylitis, meningitis and brain abscess. Others include perforation of the tympanic membrane, chronic otitis media and hearing loss. There is evidence that repeated bouts of otitis media may have adverse effects on speech development and language acquisition. Since the availability of antimicrobial therapy, the incidence of intracranial complications has decreased. In the pre-antibiotic era, three percent of cases of otitis media were associated with intracranial complications such as mastoiditis and lateral sinus thrombosis (5). An irritable baby needs a calm, proper and appropriate work-up to discover the cause of irritability. It is not enough to reassure the mother. Every effort must be made to be certain that there are no medico-surgical reason for the present illness. References 1. Warrel, D. A., Molyneux M. E., and Beales, P.F. (eds). World Health Organisation Division of Control of Tropical disease. Severe and Complicated Malaria. 2nd edition. Trans Roy Soc Trop Med Hyg 1990; 84 (supplement 2): 1 – 65. 2. Kochar, D. K., Thanvi, I., Kumawat, B.L., Shubhakaran, and Agarwal, N. Importance of blood glucose level at the time of admission in severe and complicated malaria. J Assoc Physicians India 1998 46(11): 923 – 925. 3. Migasena, S. Hypoglycaemia in falciparum malaria. Ann Trop Med Parasitol 1983; 77 (3): 323 – 324 4. Wurie, A.T., Wurie, I. M., Gevao, S.M., and Barrie, A. U. The effect of malaria on some laboratory parameters in Sierra Leoneon Children. Nig Qtr Hosp Med J 1998; 9(1): 1 – 3. 5. Kline, M.W. Otitis media. In: Oski’s Pediatrics Principle and Practice. 3rd Edition. McMillan, J.A., DeAngelis, C.D., Feigin, R.D, and Warshaw, J.B., (eds). 1999. Lippincott Williams and Wilkins Philadelphia 1301 – 1305. 6. Polin, R. A., and Ditmar, M.F Otitis media. In: Pediatric Secrets 2nd edition. Hanley and Babfus, Inc Medical Publishers Philadelphia. 1997: 295 – 298.