A 5-day-old female came to clinic with what parents described as a “weak” cry. She began to have less energy the night before, and was nursing less vigorously too. She was still urinating well. Her parents reported she had a normal, vigorous cry previously and that her 2-year-old sibling had rhinorrhea. The past medical history revealed a full-term infant with an uncomplicated prenatal, birth and hospital course. Her mother had rupture of membranes 1 hour before delivery and had no maternal fever. The review of systems showed the infant to have no fever, emesis, constipation, apnea, respiratory distress, stridor, cyanosis or rashes.
The pertinent physical exam showed an infant who appeared tired. Although she was able to breastfeed normally, it took 40 minutes and she had a weak cry intermittently. Her weight was 3.587 kilograms, down from her birth weight of 3.795 kilograms. She had a temperature of 99.9° rectally and the rest of her vital signs were normal. HEENT examination revealed mild clear rhinorrhea, and the rest of her examination was normal. The diagnosis of a viral upper respiratory infection causing an elevated temperature and fatigue in a newborn was made. The laboratory evaluation showed a normal complete blood count and C-reactive protein for age. Her newborn screening test was normal. A blood culture was sent. As the family lived 90 miles away from the hospital, she was admitted for observation for possible occult bacteremia or sepsis. The patient’s clinical course over the next 30 hours showed her to remain afebrile and slowly appear to feed better and for her cry and tiredness to improve to that of a normal newborn. Cultures were negative and the infant was discharged home without further problems on follow-up.
Crying is a primary vocalization for infants and small children, and remains a part of the vocalization repertoire over a person’s lifetime. Infant crying leads to feeding and nutrition for the child, protection (skin irritation from diaper contents, pain), and increased social interaction (through attempts to calm). Crying is described in terms of quantity and quality, with much written about the quantity of crying, as in the “colicky” infant. For more information about colic see What Should I Do? I Just Can’t Get Him to Stop Crying?
Less is written about the qualitative features of crying, but many parents are able to pick their own child’s cry out of many children who are crying. Seasoned clinicians are able to walk down a hallway and point out which child is hungry, tired, in pain, etc. The cry “that’s just not right” can bring worry and even panic to the heart of parents and clinicians alike.
Cries that are abnormal qualitatively may need further evaluation. For acute changes in crying, parents will often complain of “weak” cries indicating that it is not as lusty and vigorous as normal. Often this is due to a temporary infection. Abnormal cries that are consistent over time usually need further evaluation.
Qualitative descriptions of various cries includes:
- High-pitched, shrieking
- Abnormal central nervous system
- Cornelia de Lange syndrome – like a bleating lamb
- Cri-du-chat syndrome- like a cat
- Cerebral irritability (i.e. meningitis, hydrocephalus, kernicterus)
- Malnutrition especially marasmus
- Abnormal central nervous system
- Gravel in the Mouth
- Pain – long-lasting, intense, high-pitched
- Tired, cold, hungry infant – short duration, thin sounding
- Trauma to the hypopharynx
- Vocal cord paralysis
- Foreign body
- Infection – abscesses, croup, epiglottitis
- Laryngeal abnormalities
- Oropharynx abnormalities
- Tracheal abnormalities
- Vigorous and lusty
- Healthy, full-term infant
- Healthy, premature infant
- Weak or whimpery
- Muscle weakness
- Muscular dystrophy
- Myasthenia gravis
- Muscle weakness
Questions for Further Discussion
1. What is the definition of colic?
- Disease: Common Cold
- Symptom/Presentation: Crying and Colic
- Age: Newborn
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
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To view images related to this topic check Google Images.
Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:296.
Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:34-35, 414-417, 1273.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital