Irritable Infant Research Articles

The Irritable Infant in the Neonatal Intensive Care Unit: Risk Factors and Biomarkers of Gastroesophageal Reflux Disease

To determine risk factors for arching/irritability in high-risk infants and examine the significance of comorbidity and gastroesophageal reflux (GER) characteristics. Retrospective analysis of 24-hour pH-impedance studies of symptomatic infants in a neonatal intensive care unit (ICU) (n=516, 30.1±4.5weeks of gestation, evaluated at 41.7±3.2weeks postmenstrual age) was conducted. Comparisons were made between infants with >72 vs ≤72 arching/irritability events per day. We characterized risk factors for arching/irritability along with clinical, pH-impedance, and outcome correlates. Of 39 973 arching/irritability events and 42 155 GER events, the averages per day were 77.6±41.0 and 81.7±48.2, respectively. Acid reflux and impedance bolus characteristics were not significantly different between infants with >72 and≤72 arching/irritability events (P≥.05). The odds ratios (ORs) and 95% confidence intervals (CIs) adjusted for postmenstrual age and weight at evaluation were significant for risk factors of preterm birth (2.3 [1.2-4.4]), moderate or severe neuropathology (2.0 [1.1-3.6]), and presence of oral feeding at testing (1.57 [1.07-2.30]). Acid GER disease is unlikely the primary cause of arching/irritability and empiric treatment should not be used when arching/irritability is present. Prematurity and neurologic impairment may be more likely the cause of the arching/irritability. Arching/irritability may not be a concern in orally fed infants.

Neonatal Scrub Typhus with an Eyelid Eschar Masquerading as “Late-onset Sepsis”

Background: Scrub typhus is a mite-borne infection caused by the bacterium, Orientia tsutsugamushi. It is re-emerging in many parts of South East Asia, particularly in rural India. Although no age group is immune to this infection, scrub typhus in neonates is rarely suspected and reported. Here, we report a neonate with scrub typhus who was initially misdiagnosed as “late-onset neonatal sepsis.” Clinical Description: A 26-day-old exclusively breastfed infant presented with fever, vomiting, loose stools, abdominal distension, and refusal of feeds for 3 days. Examination revealed an irritable, febrile, and pale infant. She had tachycardia and facial puffiness. On abdominal examination, generalized distension with hepatosplenomegaly was noted. Blood investigations were suggestive of lymphocytic leukocytosis, thrombocytopenia, toxic granules in peripheral smear, and elevated C-reactive protein. Management: The infant was promptly started on empirical antibiotics for “late-onset sepsis.” However, in view of poor response, other possible differential diagnoses were considered. Careful reexamination revealed a necrotic ulcer covered by a yellow scab with erythematous rim on the left lower eyelid. Based on the clinical presentation and an eschar-like lesion, scrub typhus was suspected. The neonate was started on oral azithromycin and immunoglobulin M (IgM) enzyme-linked immunosorbent assay (ELISA) testing for scrub typhus came back positive. Fever subsided immediately within 48 h and the infant was discharged after 7 days. Conclusion: Acute febrile illness due to scrub typhus can affect newborns. A high index of suspicion is required for early diagnosis. Timely treatment leads to prompt clinical response and reduced complications.

P.122 The Pediatric Neuroirritability Management Protocol at the Stollery Children’s Hospital – Inspired by an Irritable Infant with GM3 Synthase Deficiency

Background: We describe an infant with a diagnosis of GM3 synthase deficiency, presenting with severe neuroirritability from birth. He required multiple admissions due to extreme agitation and caregiver burnout. Multiple pharmacological agents were tried, and the effect of each medication was modest and short-lasting at best. The literature on the management of neuroirritability in children with progressive genetic and metabolic conditions is sparse, and a neuroirritability management protocol has yet to be developed at our institution. Methods: We searched for relevant primary research and articles on PubMed. We reviewed the evidence of each pharmacological agent and added non-pharmacological strategies. We developed management guidelines for neuroirritability at our hospital. This protocol was reviewed by several pediatric neurologists and pediatric palliative care specialists at the Stollery and SickKids Hospitals. Results: We present the Pediatric Neuroirritability Management Protocol for the Stollery Children’s Hospital. Conclusions: Further study is required to assess whether this protocol can be adapted to treat irritability in the context of other neurological conditions such as hypoxic-ischemic encephalopathy and non-accidental injury. In addition, we will expand our guidelines to include other symptoms such as spasticity, dystonia, and autonomic dysfunction.

Irritable Infant with Bilateral Leg Swelling.

Irritable Infant with Bilateral Leg Swelling.

Irritable Infant: A Rare and Easy to Miss Case for Strangulated Toe

Background: Hair-thread tourniquet syndrome (HTTS) is a rare condition and it refers to the strangulation of a distal appendage by thread or hair, leading to impairment of blood flow and ischemia which if left untreated becomes a surgical emergency. It is usually misdiagnosed due to its infrequent presentation in a hidden part of the body. Case Presentation: A-3-months-old-female infant presented to a governmental institute with a history of irritability, restlessness, and continuous crying without an obvious cause. The diagnosis of HTTS was made as the third digit of the left foot was swollen and red. A surgical incision was made, and hair tourniquet was removed. The follow-up had satisfactory results. Conclusion: HTTS is a rare condition and it is vital to recognize it and provide immediate treatment. Delay of treating this medical issue can lead to strangulation of a distal appendage which may lead to impairments of blood flow and ischemia.

ASCIA‐P77: CAN CHEST X‐RAY ABNORMALITY SUGGEST EARLY KAWASAKI DISEASE

Diagnosis of Kawasaki disease (KD) requires presence of persistent pyrexia for ≥5days in absence of an infectious cause[1, 2]. Younger infants with KD often present with atypical or incomplete disease and are at increased risk of complications[3]. Certain overlapping features of KD with sepsis may cause diagnostic delay. One such feature is chest X-ray (CXR) abnormality in KD that is not frequently reported. 13 week old boy was admitted to a regional hospital in Victoria with <24 hour history of high temperature, poor feeding, irritability, diarrhoea, conjunctivitis with mucous discharge and generalised fine macular rash. Initial assessment revealed an alert yet irritable infant with dry mucous membranes, delayed central capillary refill time, high grade pyrexia, cool peripheries with normal breathing and heart sounds. Respiratory swabs, cerebro-spinal fluid, urine, blood and stool cultures and virology returned normal. Initial fluid bolus (20ml/kg) and IV antibiotics were administered on admission. Initial Hb and Albumin were low; CRP, ESR, WBC, Neutrophil and Platelet counts were raised and remained so in first 5 days of illness. CXR was suggestive of abnormal air space density in both perihilar regions in the right upper zone. Polymorphic rash was observed on day 4. Mild non-pitting oedema of hands and feet was noticed on day 5 and treatment with intravenous immunoglobulin infusion and aspirin were commenced. Irritability and pyrexia settled within hours of the infusion.2D ECHO on day 8 was reported normal. Desquamation of fingers and toes was evident on 2 week review.

Clinical Image: Omphalitis

A 13-day old baby girl was brought to the emergency department due to redness, induration and swelling of the umbilical cord. On physical exam, we found an afebrile, irritable infant with erythema and tenderness around the umbilicus

‘Sometimes they just want to cry for their mum’: couples' negotiations and rationalisations of gendered divisions in infant care

This study investigates how couples negotiate and rationalise gendered divisions in infant care. We take a social constructivist approach to analysing qualitative data from 11 couples with infants (aged 6 to 8 months). We find that even where fathers are actively involved in infant care there are strong gendered divisions in the types of care that parents provide. These divisions are rationalised by gendered discourses regarding mother's superior ability to care for and nurture infants and embedded in the ‘silences’ or taken-for-granted gendered assumptions within couple's accounts. Dominant gendered discourses implicitly defend a father's decision to opt out of infant care tasks they find more difficult, such as soothing an irritable infant. Our study contributes to work and family policy by capturing couples' care negotiations in the early stages of the parent-child relationship. This is a critical time when gendered care patterns are established within families.

An Irritable Infant and the Runaway Redback: An Instructive Case

The envenomation syndrome of Redback spider bites, lactrodectism, is distinctive. However diagnosis can be difficult due to an atypical presentation. We describe the case of a 1 year old boy with irritability, diaphoresis and reduced oral intake, in whom a diagnosis was made of redback spider bite. Successful resolution of symptoms was achieved following treatment with antivenom. The symptoms and management of redback spider bites is discussed.

Visual Diagnosis: Perceived Fevers and Back Pain in a 1-week-old Infant

1. Delia L. Gold, MD* 1. *Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH. A 7-day-old female infant presents to the emergency department with the complaints of perceived back pain and subjective fevers. Her mother also describes unexplained skin color changes to her infant's back and shoulders. For the past 2 days, the mother had noticed that her infant was fussy and would cry when her back was touched. She has no other systemic symptoms, no sick contacts, and no known history of trauma. The mother has no reported history of methicillin-resistant Staphylococcus aureus infection or colonization. This is the first time the mother has sought medical attention for her baby since discharge from the newborn nursery. The child was born by vacuum-assisted vaginal delivery at 39 weeks' gestation and weighed 3.8 kg. Labor had been induced because of maternal preeclampsia. Meconium-stained amniotic fluid was present on delivery. Apgar scores were 3 and 8 at 1 and 5 minutes, respectively. The infant did not require resuscitation and was admitted directly to the newborn nursery, where she stayed for 3 days. The mother had adequate prenatal care and no serologic evidence of prenatal infections. Of note, because the mother had one prior spontaneous abortion, she had received Rho (D) immune globulin during this pregnancy. Physical examination reveals an afebrile, irritable infant. Examination of the skin demonstrates a warm, confluent, blanching, erythematous, and somewhat purpuric area covering the upper third of her back (Fig. 1). Areas of induration are scattered over the patient's upper back and posterior axillae (Fig. 2). Shotty lymphadenopathy is noted in both axillae. The rest of the physical examination findings are unremarkable. Figure 1. Warm, confluent, blanching, erythematous, and somewhat purpuric area covering the upper third …

‘Sick’, irritable infant with fever, vomiting, bloody stool and abdominal distention (Case Presentation)

‘Sick’, irritable infant with fever, vomiting, bloody stool and abdominal distention (Case Presentation)

Infant Temperament and Parental Stress in 3-Month-Old Infants After Surgery for Complex Congenital Heart Disease

This study aimed to identify and compare differences in temperament and maternal stress between infants with complex congenital heart disease and healthy controls at 3 months of age. Study sample was drawn from an existing longitudinal study examining growth in infants with congenital heart disease when compared with healthy controls. Infant temperament and parental stress were measured in 129 mother-infant dyads. Inclusion criteria for infants with congenital heart disease were > or = 36-week postmenstrual age, > or = 2500 g at birth, surgery in first 6 weeks of life, and no major congenital anomalies or genetic syndromes. The Early Infancy Temperament Questionnaire and Parent Stress Index were the assessment tools used. Infants with single ventricular (SV) physiology were more negative in mood (F = 7.14, p < .001) and less distractible (F = 5.00, p < .008) than the biventricular physiology or Control (C) infant groups. The demands of care for infants with congenital heart disease were a source of stress when compared with Control infants (p < .05). Five of 6 subscales of the Child Domain were significant sources of stress in the SV group compared with biventricle and Control groups. Negative mood and difficulty to soothe were predictors for Child Domain and Total Life Stress in SV infants. The demands of parenting an irritable infant with SV physiology put these mothers at risk for high levels of stress. Results suggest the need for predischarge anticipatory guidance for parents to better understand and respond to the behavioral style of their infants, in particular, infants with SV physiology.

Facial palsy in a 2-month-old infant with Kawasaki disease

We read with great interest the article “Facial palsy in a 2-month-old infant with Kawasaki disease” by Kaur et al. [1] published in the November 2009 issue of Rheumatology International. Although the authors were adept in managing the infant well, I would like to share with the readers my views further on the management of the case. There are numerous reports in the literature regarding the pattern of fever in Kawasaki disease (KD). It is an extremely wellknown fact that the fever in KD is high-grade commonly unrelieved by antibiotics and is mostly partially responsive to commonly employed antipyretics. In the present instance, the authors should have suspected KD at the very outset when the infant presented to them, based on the “signiWcant” past history of 2 weeks of high-grade fever not responding to multiple courses of oral and parenteral antibiotics. Although the authors do not mention anything about the responsiveness of the fever to antipyretics, it may be safe to assume that the fever might have been suboptimally responsive to antipyretics as well. Further, the authors describe “extreme irritability” in the child. This clinical sign, although subjective, helps immensely in suspecting KD in a given child, especially in the absence of other classical signs and symptoms. At this juncture, we would like to draw the readers’ attention to a recent report published by us in which we described extreme paucity of clinical signs and symptoms in a child with KD, whose major presenting features were prolonged fever unresponsive to antipyretics and “extreme irritability” [2]. This was followed by another similar report from Turkey by Yilmazer et al. [3]. We believe that instances of KD essentially represent a spectrum with some children on one end manifesting hardly any of the well-known signs and symptoms besides fever, while others at the opposite end of the same spectrum manifesting all the classical signs and symptoms. With increasing recognition of the incomplete forms of KD, and the diYculties associated with diagnosing such cases, the American Heart Association expert committee, 2004 recommended fulWllment of the supplemental laboratory criteria to assist clinicians in diagnosing “incomplete” forms of KD in the presence of two or three clinical signs [4]. These include anemia for age, serum albumin 450,000/mm, white blood cell count (WBC) >15,000/mm and urine >10 WBC per high power Weld. Under these circumstances, treatment with intravenous immunoglobulin (IVIG) is recommended before an echocardiogram is obtained. With regards the infant discussed, supplemental laboratory tests were positive on admission. Given the fact that the authors had an extremely irritable young infant with high-grade antibiotic unresponsive fever of 2 weeks duration with several additional tests of systemic inXammation strongly positive, we feel an immediate twodimensional echocardiography should have been carried out at the very outset to exclude coronary artery changes followed immediately by treatment with IVIG and highdose aspirin without waiting for other signs and symptoms to appear.

Baby Lost and Found: Mothers' Experiences of Infants Who Cry Persistently

Introduction The purpose of this study was to describe mothers' experiences of parenting an irritable infant. Although “colic” is regarded as a “self-limiting” condition that usually disappears by 3 to 4 months of age, the entire family is affected by the infant's crying; no definitive cause or cure has been identified. Method Sample and setting: Twelve middle-class married mothers (mean age = 27.6 years) of irritable infants were interviewed. The women responded to open-ended questions, beginning with a description of the “typical day” with the infant. All interviews were tape recorded, transcribed verbatim, and entered into the AtlasTi qualitative analysis program. Grounded theory methods were used to analyze the data. Transcripts were read repeatedly to verify coding and emerging concepts. Results The basic social psychological problem was the loss of the perceived baby and competence as a mother. The psychosocial process was the search for the baby and sense of self as mother. Processes involved cycles of hope and despair and trial and error as mothers became more isolated. Discussion Implications for practitioners include support and listening to mothers during this difficult period.

Prescribing Proton-Pump Inhibitors to Irritable Infants: Where is the Evidence?

Infants with gastroesophageal reflux present with multiple symptoms, including irritability. When a physician is evaluating such an irritable infant, she/he would often prescribe a histamine 2 receptor antagonist blocker. When this fails, proton-pump inhibitors (PPIs) are often prescribed. Evidence demonstrates that there has been a fourfold increase in the use of PPIs, which may be prescribed in children as young as 2 weeks of age. This article addresses multiple issues: variable pharmacokinetics, risk of infection, absence of an adequate oral preparation, and lack of clear evidence to support the efficacy of PPIs in irritable infants. Extreme caution should be used in prescribing PPIs to this vulnerable age group, particularly those less than 6 months of age. Until more data are available, we suggest that PPIs should be used only in infants with well-documented gastroesophageal reflux disease or as part of a clinical trial.

Letters to the Editor

24 July 2006 Dear Editor, EXCESSIVELY HIGH DOSES OF OMEPRAZOLE BEING USED IN INFANTS I would like to raise a case history that illustrates an increasing trend of prescribing supra-therapeutic doses of Omeprazole to infants. A 6-month girl presented for assessment of poor sleeping. At 6 weeks of age, she had been an irritable infant and was prescribed Omeprazole with a presumptive diagnosis of ‘silent reflux’, by a paediatrician. She initially started 5 mg daily. This was increased to 10 mg daily and subsequently to 10 mg twice daily at 3 months of age because of a lack of effect. Her parents had felt that the dose of 10 mg twice daily had reduced her vomiting and helped her generally over the course of 4 weeks. She had continued the dose of 10 mg twice daily. At her presentation, her weight was 6.6 kg and therefore the dose was 3 mg/kg/day. One could assume that at 3 months of age the dose had been significantly higher on a per kg basis. Her parents were advised that the dose of Omeprazole was excessive and that 5 mg twice daily (1.5 mg/kg/day) was a more reasonable dosage, but they were reluctant to change the dose. The Melbourne Paediatric Drug Doses Handbook (12th Edition, Frank Shann) recommends a routine dose for Omeprazole to be 0.4–0.8 mg/kg once to twice a day. If a child has Zollinger Ellison Syndrome, then the recommended dose is 1 mg/kg once to twice a day to a maximal dose of 3 mg/kg/day.1 The MIMS annual recommends Omeprazole to be used in children >12 months of age, and reports no pharmacokinetic information in children <12 months of age.2 There is limited evidence of the use of proton pump inhibitors in infants.3 There have been case reports in adults of acute overdosage, showing little adverse effect,2, 4 but there is little information in adults or children being given supra-therapeutic doses for long periods and whether this causes more problems. Population-based adult data in England have shown relatively common side-effects, such as abdominal pain, diarrhoea, vomiting and headache.5 Rarely, hepatitis and interstitial nephritis have been associated with the use of Omeprazole.6 The off-label use of Omeprazole in infants <12 months of age is common. A frequent scenario is a 6-week infant being treated for infant irritability, diagnosed as gastro-oesophageal reflux. This is despite increasing evidence showing that there is little association between infant irritability and gastro-oesophageal reflux.7, 8 Indeed, when irritable infants with gastro-oesophageal reflux are treated with Omeprazole, there is no added clinical effect when compared with placebo.9 Infant irritability is a concerning symptom, for which parents bring their children for medical attention. It remains tempting to ‘medicalise’ the problem, as other options, such as behavioural management, can be time-consuming. As there is a natural improvement of infant irritability over time, any treatment in this age group can appear to help. It is my opinion that infants should not be given ongoing acid suppression therapy for the management of infant irritability, particularly if no benefit is gained. The practice of giving ‘supra-therapeutic doses’ of Omeprazole is concerning. There is a need to gain pharmacokinetic data in children <12 months of age. I would also encourage clinicians to report any adverse effects from treatment with Omeprazole.

Clinician's Corner

five-month-old female infant who was born at24 weeks gestational age presented with a five-weekhistory of an erythematous eruption that began in the per-ineum. It progressed to involve the entire lower face, withareas of excoriations and erythematous crusted patchesaround the mouth and distal extremities.The rash did not respond to oral nystatin or topicalterbinafine. Due to the persistence of the rash and an inter-current upper respiratory tract infection, the patient pre-sented to the emergency department. Upon review ofsystems, the patient had mild diarrhea and no history ofalopecia. She was exclusively breastfed. The patient’s pasthistory included respiratory distress syndrome, bronchopul-monary dysplasia, retinopathy of prematurity and gastroe-sophageal reflux disease.Physical examination revealed an irritable infant. Shehad an axillary temperature of 37.8°C. The rest of her vitalsigns were normal. She had multiple confluent macu-lopapular lesions over her perioral and perineal area(Figures 1 and 2), with erosions, desquamation and crust-ing. Her fingers and toes were similarly affected, with spar-ing of the inframammary, labial and gluteal creases. Therest of the examination was normal.The infant was admitted to hospital and started onintravenous cloxacillin for impetigo. A diagnostic test wasperformed on admission, which revealed the diagnosis.

Clinician's Corner

five-month-old female infant who was born at24 weeks gestational age presented with a five-weekhistory of an erythematous eruption that began in the per-ineum. It progressed to involve the entire lower face, withareas of excoriations and erythematous crusted patchesaround the mouth and distal extremities.The rash did not respond to oral nystatin or topicalterbinafine. Due to the persistence of the rash and an inter-current upper respiratory tract infection, the patient pre-sented to the emergency department. Upon review ofsystems, the patient had mild diarrhea and no history ofalopecia. She was exclusively breastfed. The patient’s pasthistory included respiratory distress syndrome, bronchopul-monary dysplasia, retinopathy of prematurity and gastroe-sophageal reflux disease.Physical examination revealed an irritable infant. Shehad an axillary temperature of 37.8°C. The rest of her vitalsigns were normal. She had multiple confluent macu-lopapular lesions over her perioral and perineal area(Figures 1 and 2), with erosions, desquamation and crust-ing. Her fingers and toes were similarly affected, with spar-ing of the inframammary, labial and gluteal creases. Therest of the examination was normal.The infant was admitted to hospital and started onintravenous cloxacillin for impetigo. A diagnostic test wasperformed on admission, which revealed the diagnosis.

GERD and crying: Cause and effect or unhappy coexistence?

GERD and crying: Cause and effect or unhappy coexistence?

Diabetes insipidus.

Diabetes insipidus.