eLetters to:

ARTICLES: Stephen B. Freedman, Nesrin Al-Harthy, and Jennifer Thull-Freedman The Crying Infant: Diagnostic Testing and Frequency of Serious Underlying Disease Pediatrics 2009; 123: 841-848 [Abstract] [Full text] [PDF]

eLetters: Submit a response to this article

eLetters published:

Child Abuse is also an Important and Serious Cause of Crying in Infants

Rachel P. Berger, Cindy Christian, Allan DeJong   (16 March 2009)

Urine Evaluation in Crying, Afebrile Infants: Does the Study's Data Support This Recommendation?

Carmina Erdei Grozavescu, Shuba Kamath and Arvin Garg   (20 August 2009)

Child Abuse is also an Important and Serious Cause of Crying in Infants 16 March 2009
Rachel P. Berger, Pediatrician Children's Hospital of Pittsburgh, Cindy Christian, Allan DeJong Send letter to journal: Re: Child Abuse is also an Important and Serious Cause of Crying in Infants rachel.p.berger{at}gmail.com Rachel P. Berger, et al.	In their study “The Crying Infant: Diagnostic Testing and Frequency of Underlying Disease” Freedman et al. state that their objective was to “determine the proportion of children evaluated in an ED because of crying who have a serious underlying etiology.”1 Unfortunately, the design of the study has several important flaws which resulted in the inability to properly identify infants in whom the serious underlying etiology of their symptoms was unrecognized child abuse. In addition, the conclusion that a urine analysis is the only test which should be routinely performed in crying infants is not supported by the data presented. It is well-recognized that infants who are victims of child abuse and particularly abusive head trauma (e.g. shaken baby syndrome) often present with non-specific clinical symptoms such as crying and irritability.2-4 In these infants, the physical examination is often normal and there is rarely, if ever, a history of trauma provided. The inability to rely on the history and physical examination in these infants is the reason why there has been significant effort to develop other screening tools5 and to educate physicians about crying as a possible sign of trauma. It is also the reason why the authors’ conclusion that the history and physical examination “remains the cornerstone of the evaluation of the crying infant” is flawed. If infants who are victims of physical abuse are not properly identified as being abused, they are at high risk of re-injury and/or death. In a landmark study of infants with missed inflicted traumatic brain injury,6 65% of infants with inflicted traumatic brain injury who presented initially with irritability/crying were misdiagnosed at the first encounter. Of the infants with missed inflicted brain injury, 28% were re-injured as a result of the missed diagnosis and four of the five deaths in the study might have been prevented with earlier diagnosis. Because of the reliance on parental report 9-18 months after enrollment and on hospital records, the design of the study by Freedman et al. is inadequate to identify infants who later presented with child abuse to a different hospital or directly to a coroner. Despite the inherent flaws in the design of the study and the fact that not even one of the 237 infants underwent a head CT or a skeletal survey to evaluate for physical abuse (as per Table 5), close review of Table 5 and 6 suggest that three children were nonetheless diagnosed with trauma as the etiology of their crying. Table 5 indicates that one child underwent a skull radiograph (not the recommended diagnostic test to evaluate for a skull fracture7) which demonstrated a skull fracture; one wonders why this child did not subsequently undergo a head CT to evaluate for possible intracranial hemorrhage. Of note, this skull fracture is not listed as a serious underlying diagnosis in Table 6, although another child with a clavicle fracture is listed as is one with an epidural hematoma. We are unclear how either of these diagnoses could have been made without a chest x-ray and a head CT, respectively. If there are truly three infants who presented with crying and had a traumatic etiology for their crying, as the data suggest, then an equal number of infants were diagnosed with trauma as the etiology of their crying as with an unsuspected UTI. Given the authors’ conclusion that afebrile infants with crying “should undergo urine evaluation,” one would also reasonably conclude that these infants should undergo an evaluation for trauma as well. In summary, we are highly concerned that the study by Freedman and colleagues fails to adequately address the possibility of trauma as an etiology of crying in an infant. While abusive head trauma is the injury which is most associated with crying, other occult injuries including abusive fractures, intraoral injuries and intra-abdominal injuries also may present with crying. Since the history and physical cannot be considered as the basis for determining the necessary diagnostic testing in these infants, physicians must maintain a high level of suspicion for trauma in any infant with crying. References: 1. Freedman SB, Al-Harthy N, Thull-Freedman J. The crying infant: diagnostic testing and frequency of serious underlying disease. Pediatrics 2009;123(3):841-8. 2. Singer JI, Rosenberg NM. A fatal case of colic. Pediatr Emerg Care 1992;8(3):171-2. 3. Trocinski DR, Pearigen PD. The crying infant. Emerg Med Clin North Am 1998;16(4):895-910, vii-viii. 4. Poole SR. The infant with acute, unexplained, excessive crying. Pediatrics 1991;88(3):450-5. 5. Berger RP, Dulani T, Adelson PD, Leventhal JM, Richichi R, Kochanek PM. Identification of inflicted traumatic brain injury in well-appearing infants using serum and cerebrospinal markers: a possible screening tool. Pediatrics 2006;117(2):325-32. 6. Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma. Jama 1999;281(7):621-6. 7. Schutzman SA, Barnes P, Duhaime AC, et al. Evaluation and management of children younger than two years old with apparently minor head trauma: proposed guidelines. Pediatrics 2001;107(5):983-93. Conflict of Interest: None declared
Urine Evaluation in Crying, Afebrile Infants: Does the Study's Data Support This Recommendation? 20 August 2009
Carmina Erdei Grozavescu, Pediatric resident Floating Hospital for Children at Tufts Medical Center, Shuba Kamath and Arvin Garg Send letter to journal: Re: Urine Evaluation in Crying, Afebrile Infants: Does the Study's Data Support This Recommendation? cgrozavescu{at}tuftsmedicalcenter.org Carmina Erdei Grozavescu, et al.	We read with great interest Freedman et al.’s paper on the diagnostic testing and frequency of serious underlying etiology (1) in afebrile crying infants and we have the following comments: We agree with the authors’ conclusion that the history and physical examination should remain the cornerstone of evaluation of the afebrile crying infant. However, Freedman et al. conclude that afebrile infants in the first month of life should undergo urine evaluation. We do not believe that their results support this statement since there was a low rate of urine evaluation in infants reported in their study. Specifically, only 19/60 infants less than one month of age had urine cultures obtained. This suggests that almost 70% did not have cultures performed. Over 97% of these infants appeared to have done fine (one infant appears to have been subsequently diagnosed with a urinary tract infection), and ended up having no underlying serious etiology despite not having a urine evaluation performed. Moreover, the overall rate of positivity of urine cultures was 2.9%. Although, the authors state that asymptomatic bacteriuria has been reported to occur in up to 1% of children less than 60 days of age (2); another study suggests that the prevalence of asymptomatic bacteriuria can be as high as 3% (3). Thus, the study subjects with positive urine cultures may have had asymptomatic bacteriuria. Prospective studies are clearly needed to determine the true incidence rate of urinary tract infections in crying afebrile infants. The authors’ intention was to study crying afebrile infants. However based on their selection criteria, we believe they may have included a much broader study population. First, the authors did not exclude children who had a tactile fever at home (17%). According to evidence in the literature, tactile measurement of fever is very sensitive and specific (4). Second, the authors reported that 61 children (26%) were given antipyretics at home; this may have masked a fever, along with a serious underlying etiology, in infants presenting to the emergency department. Third, the search terms that Freedman et al. used were “cry”, “irritable”, “fuss”, “scream” and “colic”. These terms are not necessarily synonyms. Colic and irritable represent two different ends of the spectrum and may raise different concerns depending on the age of the child. Using all of these diagnoses as search terms might have under-reported or over-reported the number of serious underlying etiologies. In summary, our primary concerns are that the study population may not be homogenous, and that the results do not support the authors’ conclusion that all crying afebrile infants less than one month of age should routinely undergo urine evaluation. While we do not necessarily disagree that this may be an appropriate approach, the study has insufficient data to support this recommendation. References: 1. Freedman SB, Al-Harthy N, Thull-Freedman J. The crying infant: diagnostic testing and frequency of serious underlying disease. Pediatrics 2009; 123(3):841-8. 2. Wettergren B, Jodal U, Jonasson G Epidemiology of bacteriuria during the first year of life. Acta Pediatrica Scandinavia 1985; 74(6): 925-933. 3. Linshaw M Asymptomatic bacteriuria and vesicoureteral reflux in children. Kidney International 1996; 50:312-329. 4. Graneto, JW, Soglin DF.: Maternal screening of childhood fever by palpation. Pediatric Emergency Care, 1996; 12(3): 183-4. Conflict of Interest: None declared