Patient Presentation
A 4-month-old male was transferred from an outside emergency room for treatment of a femur fracture. The infant had presented after his mother returned from work and was told that the infant had been irritable for about 2 hours. He had been in the care of her new boyfriend who said that the infant was normal until he became irritated. The boyfriend said he had tried to calm the infant by walking and cuddling but the infant would not calm down. He also had tried a bottle which the infant refused and changing a diaper also did not change the irritability. The mother had noted that the infant became more irritated when he was moved and really irritated when she changed his diaper too. The mother said he had been well when she left him in the morning.
The past medical history showed a full-term infant who had received his routine care and vaccinations. The social history showed that this was the first infant for the mother but the father had 2 other children who were not in his care. The parents were unmarried and the father was working part-time.
In the emergency room, the pertinent physical exam showed an irritated infant who seemed to calm somewhat when he wasn’t being handled. His vital signs were normal with growth percentiles in the 25-50%. HEENT was normal with a flat anterior fontanelle. Heart, lungs, and genitourinary systems were normal. The patient seemed to not want to move his left leg and it appeared more swollen in the femur but he had normal capillary refill, good pulses and normal deep tendon reflexes. The rest of his examination was normal.
The diagnosis of an extremity problem was made and the plain radiograph showed a femur fracture. The patient was placed into a splint and transferred to the regional children’s hospital for treatment and further evaluation of non-accidental trauma.
Discussion
Child abuse or non-accidental trauma is a clinical diagnosis. It is the constellation of history, physical examination, radiographic evaluation, laboratory testing and investigation that determines if child abuse has occurred. Irritability caused by fractures or other trauma can be a presenting symptom of abuse. Fractures can be a presentation but they are also common problems not associated with abuse. Femoral shaft fractures are estimated to account for only 1.6% of all fractures in children, therefore they are potentially more suspicious for child abuse. A review of femur fractures can be found here. A review of non-accidental trauma can be found here.
Learning Point
Irritability has different meanings to different people and in the context they are used. Irritability in the medical sense is thought to be caused by the body being abnormally excited or sensitive causing the child to have exaggerated or excessive crying. The inability to be soothed usually helps to differentiate the child who is more accurately described as fussy or hard to please, bothered or is burdensome or troublesome, or even cranky or ill-tempered and grouchy. An irritable child who is also lethargic (i.e. having abnormal drowsiness or sleepiness) is much more clinically concerning than a child who is fussy and tired or fatigued.
Some problems may be more common in certain age groups but many can be found in all age groups.
The differential diagnosis of irritability includes:
- Neonatal
- Normal body sensations – wet, cold, loud noises
- Arrhythmia and/or heart failure
- Central nervous system abnormalities
- Genetic problems
- Hypoxia or hypoxic ischemic encephalopathy
- Infection including sepsis and meningitis
- Neonatal withdrawal syndrome
- Metabolic problems
- Inborn errors of metabolism – phenylketonuria, urea cycle defects
- Pain
- Young infant
- Normal body sensations – sleep deprivation, hunger or overfed, too hot or cold, constipation, urinary retention, being wet, loud noises, difficulty breathing, pruritis, fever
- Arrhythmia and/or heart failure
- Epilepsy
- Celiac disease
- Colic
- Infection – sepsis, meningitis, otitis media, urinary tract infection, gastroenteritis, pneumonia
- Metabolic problems
- Inborn errors of metabolism – phenylketonuria, urea cycle defects.
- Pain – trauma, reflux, stomatitis, rash/pruritis, corneal abrasion, etc.
- Teething
- Older child
- Normal emotions – angry, annoyed, bored, frustrated, excited, inability to communicate
- Behavior problems – attention problems, bullying, temperamental mismatch
- Social insecurity and adverse childhood experiences
- Normal body sensations – sleep deprivation, hunger or overfed, too hot or cold, constipation, urinary retention, being wet, loud noises, difficulty breathing, pruritis, fever
- Arrhythmia and/or heart failure
- Anemia
- Brain tumor
- Epilepsy
- Food intolerance
- Infection – sepsis, meningitis, otitis media, urinary tract infection, gastroenteritis, pneumonia
- Metabolic problem – hypoglycemia, hypercalcemia
- Medications or substance abuse
- Psychological problems – anxiety or mood problems, mania
- Pain – trauma, reflux, stomatitis, rash/pruritis, corneal abrasion, etc.
- Teething
Question for Further Discussion
1. What recommendations do you give for a colicky or crying infant? A review can be found here.
2. What causes lethargy? A review can be found here.
3. What are the criteria for the Glasgow Coma Scale?
Related Cases
- Disease: Fractures | Child Abuse | Infant and Newborn Care
- Symptom/Presentation: Crying and Colic | Child Abuse and Neglect and Sexual Abuse | Mental Status Changes
- Age: Infant
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Common Infant and Newborn Problems, Child Abuse, and Fractures.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Sheldon SH, Levy HB. Pediatric Differential Diagnoses, 2nd. Edit. Raven Press, NY, NY. 1985:107-109.
Illingworth RS. Common Symptoms of Disease in Children. 9th Edit. Blackwell Scientific, Oxford, UK.1988;220-21.
Sukhodolsky DG, Smith SD, McCauley SA, Ibrahim K, Piasecka JB. Behavioral Interventions for Anger, Irritability, and Aggression in Children and Adolescents. J Child Adolesc Psychopharmacol. 2016;26(1):58-64. doi:10.1089/cap.2015.0120.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa
Pediatric Education 